Is overweight good?

The flu is the worst.

Try to not get it. Speaking of health: Is it actually bad to be fat? This is something people ask me about all the time, no more often than this time of year, the new year, when people are trying to make new commitments to a new and better lifestyle — or, at the very least, they're trying to undo the damage they did to their bodies during the winter holiday eating and drinking merriment season.

I'm right there with you. And I am not a physician or any kind of medical scientist. I'm just a nerd who eats and reads a lot, and I'm pretty up to date on the scientific literature on this topic. I am also constantly conversing and corresponding with researchers on the forefront of this topic. And for what it's worth, I'm going to tell you whether I think it's actually bad to be fat.

Short answer and long answer. Short answer is — being very fat is probably very bad for your health long term. There are young people who are very fat who are perfectly healthy, but as you track them through their lives as they age, their health really starts to suffer as compared to their leaner peers. People who make the most extreme version of the argument that you can be healthy at any size have to cherrypick their data to support their assertion — sure, being obese does not seem to hurt people very much in the short term, and young people in general are pretty resilient to all kinds of physiological stresses, but in the very longterm — over the decades of our lives, people who are carrying a lot of body fat for decades and decades tend to have significantly worse health outcomes.

The correlation between chronic, longterm obesity and really bad health is definitely there. The correlation between obesity and increased risk of cardiovascular disease, diabetes, certain cancers and osteoarthritis — this a very strong correlation. It is as well-documented, as "proven" as, like, anything else in science. If you reject the correlation, you reject all of science.

Of course, correlation is not causation. We don't know for sure if being very fat is the thing that causes the heart attack, or if there's another thing that causes the heart attack and also, separately, incidentally, causes you to be very fat. We don't know that for sure, and it probably depends on a case by case basis. Whether the body fat itself is bad for you seems to depend on the particular kind of fat tissue you have in abundance, among other factors.. That said, sometimes the distinction between correlation and causation is not very important in practice. Most of the things you could do to make a very overweight, very unhealthy person a little bit more healthy will also probably make them a little less overweight, and vice versa. Eating less garbage food and moving around more will almost certainly make you healthier and, perhaps incidentally, it may also make you a little leaner. It's definitely possible to eat a healthy diet and at the same time be a little overweight, but it's tough to force your body to hold hundreds of pounds of adipose tissue (body fat) only through eating fresh fruits and vegetables and whole grains and lean protein.

You'd have to be cooking and eating nearly every waking minute of your life to keep yourself extremely fat on a good diet like that — a diet that does not include substantial doses of Doritos and Twinkies and soda and other extremely concentrated calorie bombs that are otherwise nutritionally vacuous.

It's certainly possible to get a lot of good exercise and also be somewhat overweight, but most people who are extremely obese are also totally sedentary, in part because at some point you get so big that it's just prohibitively hard to move around. Is being fat causing you to not get exercise and therefore lose out on all the well-documented health benefits of exercise, or is not exercising causing you to be fat? In practice, the difference might not actually matter that much. A high level of adiposity — carrying lots and lots of body fat — seems to be an imperfect, but still pretty good proxy for overall metabolic health. Being very fat might be the thing making you unhealthy, or it might simply be an incidental symptom of the other thing that's actually making you unhealthy, like eating tons of sugar. But regardless, most of the things that would make you more healthy will also result in you carrying at least a little less body fat, and vice versa. Fatness might not be the problem, but in practice, it might be a good enough proxy for the problem, though there are some notable, proven exceptions to what I just said, which we will get back to. All that established, the social and medical stigmatization of being fat is also harmful to people's health.

That is more of an emerging area of research, but we're seeing lots of new studies indicating that people who are fat get into easily avoidable health trouble because they're afraid of going to the doctor, because they're afraid the doctor is gonna weigh them and shame them. We're seeing lots of studies about how fat people who do go to the doctor tend to get worse care, perhaps because doctors and nurses just assume that your problem is that you're fat, so they don't dig around hard enough for other problems you may have. Or maybe, on a subconscious level, doctors and nurses think you aren't deserving of the highest quality care — "Why should I take care of you if you're not gonna take care of yourself," that kind of thing.

This is to say nothing of the

Chronic health problems created by the emotional stress of having your body stigmatized all your life.

Negative social cues result in physiological stress responses that really hurt your body over time. I don't know this, and I don't think anyone knows this, but it may well be possible that stigmatizing fatness is actually worse for us than the fatness itself. There are a couple studies that have come to that conclusion, but you really can't go by one or two studies on a topic as incredibly complicated and multifactorial as this one is. It is not yet proven that the stigma is worse for us than the body fat.

But I won't be surprised if it is proven over time via the accumulation of many studies with different methodologies all coming to very similar conclusions, that the shame is actually worse for our health than the fat is. Another thing nobody knows is how to fix obesity on the population level. Yes, it is fundamentally a matter of calories in, calories out. If you burn more than you eat, you will shrink — no other outcome is physically possible under the basic law of conservation of energy and matter. You can't make something out of nothing. However, some people seem to find it much harder to maintain a calorie deficit than other people do. It's probably not just that some people have more willpower. There are people who go into calorie deficit and they get way stronger hormonal hunger signals from their body — they are so overcome by hunger and tiredness and brain fog and depression and insomnia that they simply cannot function in a significant caloric deficit.

Even if they commit to just sitting down and suffering through the weight loss — they basically put their productive lives on hold for a few months to focus on nothing but enduring the incredible pain of losing the weight — even if they do that and they settle into caloric balance at a much lower weight, they're not in deficit anymore, yet they are still beset by overwhelming hunger, perhaps because of hormonal and metabolic changes caused by the weight loss process itself — the weight loss process made them permanently hungrier, and the only way that they can maintain that new, lower weight is if they basically do nothing else with their time and effort but resist the urge to eat, which of course most people cannot afford to do, nor should they.

There are simply more important things to do in life than to sit around and grind your teeth all day to keep from eating too much. You need the food energy necessary to live a productive life, and some people's bodies seem only able to derive that necessary energy at a higher level of adiposity, and/or at a significant caloric surplus, which results in a high level of adiposity over time. Another thing nobody knows for sure is how fat is too fat — what level of body fat is either directly bad for you, or is at least correlated with bad things happening to you. Nobody knows for sure how fat is too fat. It's certainly a spectrum, not a switch, and it's probably not just one spectrum. There may be significant individual variation on how fat is too fat, as far as health is concerned. However, on the individual level, all of us reserve the right to feel our own feelings and to make our own choices that will help us to be the way we want to be, for whatever our own reasons are.

Just as I don't want to shame you for carrying body fat, I also don't want to shame you for trying to lose it, for whatever your own damn reasons may be. If your reasons are purely cosmetic, that’s your own business. It’s important to be able to attract a mate if you want one, and you may find that you have to be leaner to attract the kind of mate you want, and so if you want to work hard to be leaner, my hat is off to you. As Dan Savage always says, if you’re not getting love and sex from the people from whom you want love and sex, then the only thing to do is to change yourself into someone who is more worthy of love and sex. That’s some tough love on his part, and there is an unfortunate aspect of ableism inherent in that argument, but it’s better than the alternative ideology that is bubbling up in the most godforsaken corners of the internet these days — the kind of patriarchal revanchism preached by incels — boys who will not earn love and sex on a free and open market, therefore they want to reinstitute a highly regulated market in which women do not have free choice of partners.

They want to go back to the days when women were admonished to only have sex within monogamous, heterosexual marriage, thus guaranteeing that for every man there will be one available woman whose only choice to live a life with intimacy is to marry one of the dregs left at the bottom of the barrel, thus guaranteeing him lifetime access to sex that he does not have to earn by working to be attractive.

Here in the developed West, we have more or less torn down that institution for a reason — it effectively forced people into lifelong commitments that they did not want, which is evil. But the alternative isn’t great either.

It does suck that people have to suffer and hurt their bodies in order to warp themselves into forms that will be more viable on a free and open market for love and sex, but I also think people overestimate the extent to which they actually have to do that. You don’t need a gym membership to cultivate your kindness and your empathic imagination and your capacity to be a good hang. Those attributes go a long way toward earning you companionship and intimacy, as does learning how to cook. Plus, for every body type, there is someone with a matching body who also desires companionship and intimacy — at least there is nowadays with the internet where you are no longer limited to the dating pool in your own tiny town. Anyway, fat loss.

I have made content intended to help

People lose body fat, if they want to.

I have accepted a few sponsorships from

Companies that aim to help you lose body fat, among other goals.

I have zero regrets about doing that.

I will do it again, because some people can substantially change their bodies, and if they want to, for whatever reason, then that is their own damn business. But if people just want to make peace with how their body seems to be naturally, and if that is with a fair bit of adipose tissue, then I support them 100%. All things considered, that may actually be the healthiest thing to do, in practice — just chill out and go with the flow, because in practice most people seem to have very little ability to get substantially leaner and to stay that way. The forces that are rapidly making us fatter as a species are really big and diffuse and multifactorial and not well understood. Nobody knows for sure the full story of why obesity is happening to us, and we know even less about how to stop it. If you're watching the version of this episode, there's a Q-colde up now that you can just snap with your phone camera if you want try Aura 14 days free. Being that I live in the United States and I own my home, my address is a matter of public record.

It's in the tax records, and if you know how to search such things, you can find where. I live. But most people don't know how to search such things, or they don't want to put forth the effort. Crazy people who want to come egg my house — or, more likely, junk mailers and robo-callers — they just want to go to a data broker that automatically scrapes all the tax records. I'm talking about these people finder websites — they write programs that suck up tax records and put them into easily searchable databases online. The good thing about these people finder companies is if you fill out a form asking them to take your info down, they'll do it. On the regular, they submit takedown requests to these people finder websites on your behalf, and it works.

I was slowly giving up on grad school, living off of loans, I had basically no real responsibilities, and I was just riding my bike all the time — hundreds of miles a week.

I loved every minute of it.

I loved distance cycling and also climbing – sprinting hills. Shout out to Boltinghouse Road, Bloomington's best hill. Ridiculously steep — the kind of hill that when you drive up it in a car, you’re worried you’re going to fall backwards. I used to sprint up Boltinghouse, fly back down, turn around, sprint back up again and do that until I literally couldn't push the pedal another turn. It was awesome. As a result of being on the bike non-stop I got down to about 125 pounds, at 5 foot 8 inches tall, while still carrying a bit of muscle, and muscle is way heavier than fat.

That's the only time in my life when I had visible abs. I absolutely loved riding my bike nonstop, but I did not like being that lean. That level of leanness is physically uncomfortable. Your butt is just boney. It hurts to sit on anything that isn't generously padded. It's hard to sleep when I'm that lean — my body is sending me hardcore hormonal signals — it's saying, "get up, get out of bed, go find food, we're starving, we can't just be lying around, we have to go find food, wake up, wake up.". Insomnia is a very common symptom of either being too lean or in too steep of a caloric deficit. Another common symptom is very low sex hormones.

The reasons for that are complex. Part of it is your body simply needs a certain level of dietary fat in order to biosynthesize your hormones. Part of it is that male sex hormone, testosterone, causes the body to do a lot of costly things that are not necessary to survival, like hoarding protein in the form of skeletal muscle. Your body is quite logically evolved to stop doing unnecessary things when it thinks it is starving. Your testosterone plummets, and as a result your body can use more of your meager food intake for more essential tasks, like keeping you upright and moving around. Your body figures, "Well, we'll get strong enough to compete for a mate another day, when there's more food around," and your T plummets. So when I'm very lean and/or when I'm in very steep caloric deficit, my sex drive plummets. This was less of a problem when I was 23, but it's been a bigger problem every year since then.

When I'm very lean, people want to have sex with me but I don't want to have sex with them, so what's the point? I don't want to be extremely lean. It's not a good way to live. For me. Some people are genetically predisposed to being very lean and they find that a perfectly comfortable way to be, and that is awesome. For me, and probably for you, being extremely lean is constant waking torture. On the other hand, I don't want to be very fat. That's also not a good way to live. I've been there.

It's just hard to move around. You're carrying an 80 lb military hiking pack everywhere you go, and it's exhausting. When I'm really overfat, I get depressed.

Some of that is certainly due to

Bullshit social stigma.

Oh — and if you hadn't noticed,

We've already transitioned into the long answer to the "is it bad for you to be fat" question, and the long answer will be the rest of this episode.

I'll throw some footage on the screen of what I look like with most of my clothes off. I wasn't in quite as good shape a year and half ago when Mr Lovemaker Steam sent me that email, but it was not a huge difference. I basically looked like that, which lots and lots of people would be very happy to look like. Mrlovemakersteam has absolutely absurd standards for what a good body composition is. And when I'm carrying more body fat, the fact that I am depressed is certainly due in part to the absolutely absurd social standards of internet dung beetles like MrLovemakersteam. There's a very cool 2021 study out of the UK looking at the association between obesity and depression. One of the lead authors is Jessica O’Loughlin at University of Exeter, whose work I follow.

She's right on the cutting edge of the science on weight and mental health. O’Loughlin and company analyzed large-scale, observational data for 145-thousand European people, and they used the shiny new statistical tool that all the cool kids are using now, which is Mendelian randomization. It's named after Gregor Mendel, the 19th century father of the study of genetics, and it's a relatively new way of using genetics to tease out causal relationships. Giant observational studies are great at revealing correlations — like, obese people are more likely to to get cardiovascular disease — but those studies are terrible at telling you why. Basically, and I am really dumbing this down, mostly because I myself am relatively dumb. But basically, with Mendelian randomization, you look for some usually really subtle genetic variation that is strongly correlated with exposure to some thing, like a thing people eat. And you use that genetic variation as a proxy for the exposure that you're trying to study. And by comparing people who exhibit that genetic variation against people who don't exhibit that variation, you can tease out how much of their health is attributable to said exposure.

That was a terrible explanation of Mendelian randomization. One of these days I'm gonna get an actual expert to help us understand this. But anyway, Dr. O'Loughlin and colleagues, in this 2021 study in the journal Human Molecular. Genetics, used Mendelian randomization to try to figure out why obese people tend to be depressed and vice versa. And their math indicates that much of the excess depression experienced by obese people is simply due to psychosocial effects — fat shaming. But not all of it.

Even when you use all these new

Fancy statistical tools to eliminate the social causes, obese people are still more likely to be depressed.

One explanation that scientists talk about here is the system-wide inflammation associated with obesity. Basically, and again I am really dumbing this down, your body needs to be able to flush out metabolites — chemicals created by the action of your metabolism — it needs to be able to flush out metabolites and it only does that in times when your body is expending more energy than it is absorbing. You need to run the tank down to empty, regularly, either by fasting or by exercising, or both. If you don't, all kinds of bad stuff just builds up in your cells and in your tissues and lots of inflammatory responses ensue. I assume this is why when I'm eating way too much and moving way too little, I feel a slight burning sensation running through my whole body that is very unpleasant. It's just systemic inflammation. And these inflammatory responses also seem to affect our brains and therefore our moods. The main reason why I exercise regularly is for short-term mood maintenance.

I often really dislike exercising during the act of doing it, but almost immediately I get an improvement in my mood that lasts a day or two. If I go more than a couple days without intense exercise, I get cranky in a way that people around me really notice and tell me about. I feel kinda cranky right now because I've had the flu and so I haven't been able to exercise. I tried to work out yesterday and my body was like, "No, you are not ready for this, sit down," and that sucks. I'm doing lots of walking and that is salvaging my mood somewhat, but more intense exercise is really what I need. I can get the same effect by just not eating for a day, but it's more fun to eat and move around than it is to not eat and just sit there. This is one of the factors that goes into my personal definition of a "healthy weight" for me. I simply notice that when I carry more body fat than the amount I'm carrying now, I am less happy, and that is probably due to both social and physiological effects.

Another thing that goes in my calculation is literally how my body feels as I move around inside it. When I am significantly fleshier than I am now, I find it hard to move. My thighs rub together and that hurts. My belly bunches up between my rib cage and my pelvis when I sit and that hurts. I'm heavier, which puts more strain on my spine and on my feet and that hurts. As I get older I really feel the strain of my weight in my joints as well — the simple weight of my body and the weight of the earth mutually pulling on each other via the force of gravity and smashing my joints between them. That hurts. My body is just a less comfortable thing to inhabit when my BMI gets well above 30 or so.

Yes, I said it. Body Mass Index — perhaps the most controversial health metric of our time. BMI was invented in the 19th century by a Belgian scientist named Adolphe Quetelet, who was one of the first people to use statistics to try to predict or explain behavior. He did a lot of criminology work, documenting the links between poverty and crime, lack of education and crime, being a young man and crime — which is a very strong correlation. Young men are, statistically, the worst people. I say that with love, to the young men who comprise the plurality of my audience. But back to Adolphe Quetelet. Being that these were significantly less enlightened times, Adolphe Quetelet's work formed much of the basis of the eugenics movement and thus he is not remembered super well.

But our more enlightened view of the world is, to a large extent, enabled by the fact that we are standing on the shoulders of people like Adolphe Quetelet, so maybe we shouldn't judge him so harshly.

We have the benefit of his work

And all of the thinking that flowed out of his work — he did not.

Anyway, BMI — a statistical concept originally

Defined by an upper-class 19th century belgian guy — bmi is your weight divided by your squared height.

So I weigh 200 pounds, 91 kilograms. I'm five foot eight inches tall. That's 1.73 meters. The standard equation is kilos over squared meters. 1.73 meters squared, 1.73 x 1.73 is 2.9929.

Let's round that up to 3, because I’m actually more like 5’ 8” and a half. Divide my weight, 90 kilos by my squared height, 3 meters, and my BMI — my height to weight ratio — is 30. A BMI between about 20 and 25 is considered normal, 25 to 30 is overweight, 30 and above is obese. My BMI is 30. I'm obese? You've seen me right — do you reckon that I'm obese? The obvious problem here is that Adolphe Quetelet and the other people after him who defined this very simple measurement did so using their own bodies as the model — white European 19th century upper-class men. They naturally treated themselves as normal, and they defined everybody else as abnormal in relation to themselves. It's the equivalent of assuming that the earth is at the center of the universe because it happens to be the planet you live on. Modern science had to be around for a while before we all learned about the dangers of universalizing our point of view.

Other people tend to have higher BMIs while still being in tip-top physical condition — such as, for example, women. Women are evolved to carry more fat around their hips, in their breasts and on their butts (thank the maker for that, I say) and thus women’s BMIs just tend to be higher. Also, strong people have higher BMIs. One cubic centimeter of skeletal muscle weighs 1.04 grams. A cubic centimeter of adipose tissue, body fat, weighs.92 grams. Muscle is heavier than fat, so if you have a strong person and a weak person who displace the same volume of water, the strong person is going to have a higher BMI. And whereas high levels of body fat are generally correlated with poorer health outcomes, high levels of skeletal muscle are generally correlated with better health outcomes, to a point. Monsters on steroids don't live long either.

No one knows exactly why. Part of is probably all the ways in which the steroids themselves directly hurt you, but part of it is also probably the extra burden of maintaining and servicing all the extra tissue that a muscle monster is carrying. Whether it's muscle or it's fat, it's still extra work to pump blood to all of that tissue, for example. I don't take steroids or TRT or anything like that, and I don't have a significant genetic predisposition toward carrying skeletal muscle, as some people do, and so I don't think I'm in any danger of getting too muscly for my own good. But I do lift, and as a result, I am technically, just barely, obese, according to conventional. BMI thinking, despite the fact that my level of adiposity is, I think, only slightly excessive. But to look at me and be told that I am obese might make you think that BMI is pure bullshit, and you might be right, but scientists continue to use it, and I think they have some good reasons for continuing to use it. BMI is kinda the best thing we've got for studying the interaction of weight and health at the population level.

A better metric would factor in the type of tissue you have — is that weight fat or is it muscle? But in order to determine that, you have to do things like fully submerge a person in a water tank, see how much water they displace, and then run that through an equation that factors in the relative weight of muscle vs adipose tissue, and even that gets you only a rough estimate of your body composition, because it doesn't factor in variables like how thick and dense are your bones, what is your blood volume — these things vary a lot from person to person.

A much easier test to do is a skin fold test with calipers — they pinch your belly fat and see how thick it is, but that's even less reliable than the water tank test. In comparison, it's really easy to measure people's height and weight, they generally do it to you every time you go to the doctor, and while the measurements might not tell you very much, at least they are pretty accurate. We're simply not going to do enough of the better body composition tests on enough people in order to do large-scale observational research about weight and health. The other good thing about BMI is that we've been tracking it for a long time, and so we have a lot of data about BMI already that we can use to study phenomena over a pretty long time scale.

There's all kinds of things in science,

And dietary science in particular, that we continue to study not because it's the most important thing to study, but because we have been studying it for a long time already, and so we're kinda locked into it.

We're married to it. For example, there's the distinction between fresh meat and processed meat.

Eating fresh meat is generally associated with good health outcomes whereas eating processed meat is generally associated with bad health outcomes. The line between what is fresh and what is processed is debatable, and we may have drawn it in the wrong place. Like, is a hot dog really a processed meat? Usually they consider it a processed meat. What if it’s a hot dog that’s really minimally processed? What if it's just fresh meat blitzed into a paste and then stuffed into a collagen casing without any additives at all and then cooked fresh — should we really consider that a processed meat? Maybe not. But we have definitions of fresh vs processed meat that we've been using in dietary research for decades and decades. Longitudinal data like that is very precious and hard to come by, and if we want to keep adding to that wealth of knowledge, we need to keep collecting data about meat consumption in the same, arguably flawed way that we’ve been doing it this whole time, otherwise we're gonna be comparing apples and oranges, or hotdogs and chops, as the case may be.

BMI might suck, but it's what we've been using for decades, and so we might as well keep going with it, because at least it's something. What BMI is probably almost useless for is on the individual level.

There's no reason to use such a crude instrument to assess the health of an individual human. For example, I went in for a physical recently, and the overworked nurse who entered my numbers into a computer noticed that my BMI is 30, and she said "you'll want to watch your weight, you're getting into the obese category" and she said that without even looking up at me. Like, she barely even looked at me the entire time she was working with me, and she apparently didn't look at my blood pressure number which was excellent and basically all of my other numbers are excellent. I don't begrudge this nurse. The American healthcare system is a dumpster fire. I know it feels really bad in the UK right now, I know the NHS is really messed up right now, but by every conceivable population-level metric of healthcare quality you still have it better in the UK for way less money. The U.S. system is the money pit of despair.

I'm not mad at my nurse for not paying any attention to the eccentricities of my body and for shaming me based on a stupid ratio. I am, however, grateful for the fact that my doctor came in and actually looked at me, and said, "You look good, see you next year.". BMI is next to useless on the individual level. But on the population level, BMI is really the best information we've got. And in those big, population-level observational studies, higher BMI starts to be correlated with worse health outcomes starting around a BMI of 25. That's why they continue to classify 25 as overweight. In contrast, very low BMI is also associated with excess mortality and such. Once BMI goes below about 18, you start seeing major increases in all-cause mortality, for obvious reasons.

That is a starving person right there. Depending on how you define it and how exactly you look at the data, being underweight is arguably more dangerous than being overweight, especially in older people. But there's controversy about that science as well. Sometimes the reason that dying old people are also skinny is because they're too sick to eat, or they're too sick to absorb all their food. Nutrient malabsorption is a big problem in really old people. That's a situation where the distinction between correlation and causation is meaningful, though the practical implications are still pretty similar. The solution, or a solution remains, "hey grampa, come on, try to eat a little.

You gotta eat.

I made your favorite ziti.

Come on, humor me, eat a little, grandpa.". Having a BMI below 18, or sometimes I see it defined as below 18.5, that kind of underweight is as strongly associated with death as is having a BMI in the extreme obese ranges. Obesity, as defined by BMI, is generally divided into three classes nowadays. Class 1 obesity is a BMI of 30 to 35 — that's my class — class 2 is 35 to 40 and class 3 is 40 and above. Classes 2 and 3 are very clearly associated with terrible health outcomes. Class 1 obesity is debatable. Scientists argue about whether the data show significantly worse health outcomes for people in the overweight and class 1 obesity ranges.

That said, a BMI of 20-25 is usually associated with the longest, healthiest life, again on the population level. On the individual level, BMI is trash. There's no reason to rely on it if you want to have a sense of what your body composition is and how it might relate to your health. Ask your doctor to give you a better assessment if you really want to know where you stand. On the population level, BMI is the best we've got. My BMI is 30. A BMI of 40 and above, class III obesity, is what they call morbidly obese. Unless you're a bodybuilder on steroids, in which case you have your own major health risks to worry about, a person with a BMI of 40 and higher is probably carrying the level of body fat that is clearly, strongly associated with heart attacks and strokes, and cancers of the digestive system.

A BMI of 40 and above is almost certainly a real problem. The fat itself can be a problem. The excess weight simply puts extra stress on all your tissues, and your heart that has to pump blood through all this extra tissue, and all of the eating necessary to maintain all of that fat tissue puts extra stress on your digestive system and your liver and kidneys and all of that. However, there is surprisingly little evidence for a direct causal link between carrying body fat and dying from cardiovascular disease, for example. Very obese people are far more likely to die of a heart attack or stroke, but we don't know if it's the fat that does it, or if there are other lifestyle and genetic factors that kill you while simultaneously, separately, making you fat. This is an area of active, ongoing scientific investigation and debate. Scientists have identified cohorts of people who are obese and yet they are otherwise metabolically healthy. Their blood pressure is fine.

Their blood sugar is fine. Their blood lipids are fine. All of their labs are fine, and yet they are obese. This phenomenon has a name now — MHO, Metabolically Heathy Obesity. There's a 2021 study out of Germany where scientists looked at the data and tried to come up with a good definition of Metabolically Heathy Obesity, as it relates to cardiovascular health specifically. They looked at data from hundreds of thousands of people, several cohorts studies, such as the The Third National Health and Nutrition Examination Survey, NHANES-III, a representative sample of the whole United States population, and they found about 40% of the obese people in that cohort met their definition of metabolically healthy obesity — obese people with perfectly fine blood pressure.

40% of that U.S. cohort.

It was only 20% in their UK cohort, the UK Biobank, but that's still a really big number, right? That’s still a lot of people who are obese but their blood pressure is fine. One reason for the difference between the UK numbers and the US numbers, according to the study authors themselves, is the UK cohert is older. Higher median age in the UK study — that might explain why you have fewer obese people who are otherwise healthy.

There's reason to think that being fat

Isn't so bad for you — what's really bad for you is being fat for a long time.

That's less well understood, because it's harder to study. But there are big population studies that try to look at this. I'm looking at 2018 study out of Boston University: Association of Obesity With Mortality Over 24 Years of Weight History, Findings From the Framingham Heart Study. And yeah, over the 24 years of this very famous study, people who had been class II or class.

III obese for a very long time were just way more likely to die. People who had been obese for a long time but then lost a bunch of weight were still more likely to die than people who had never been obese at all. In fact, when they looked at obesity as just one point in time for all these people, they ended up observing the inverse — obese people were less likely to die. This is called the obesity paradox, and researchers have been trying to explain it for a long time. If you look at long-term obesity history, rather than looking at obesity as a single moment in time, then the correlation between class II and class III obesity and bad health is really strong. One explanation may be that people tend to lose a lot of weight in the last years and months of their lives as they get sick and waste away — they'll lose body fat, sure, but they'll also lose muscle and bone mass. This is called sarcopenia, and it's just a part of old age. Remember that BMI measures bone and muscle weight along with fat weight, and people's.

BMI usually plummets toward the end of their lives, therefore their BMI toward the end of their life might not be nearly as instructive as their weight through the majority of their life. The authors of this study argue that clinicians need to stop worrying about weight and start worrying about weight history. Sometimes your doctor might get on you about your weight, not because your weight is in a dangerous zone, but because you're on a trajectory. You're headed toward a dangerous zone and you're young enough that you might end up living in that dangerous zone for long enough that your time in the zone shortens your life a lot. Why? Well, there is reason to think that at least certain kinds of body fat are directly bad for you. The fat itself can be the thing that kills you — specifically visceral fat — the fat that grows in your abdomen around your intestines. Subcutaneous fat — the fat under your skin — that might not directly hurt your heart at all, but visceral fat seems to. I'm looking at a 2017 study "The molecular mechanisms of obesity paradox," and I just want to read two sentences verbatim from this paper, just to give you a taste of how complex this stuff is at the molecular level.

These two sentences are talking about "adipocytes," which are fat storage cells. "Subcutaneous adipocytes have distinctly different gene expression patterns (higher adiponectin expression and lower expression of pro-inflammatory adipokines), are better differentiated, and have increased adipogenesis and browning potential compared with visceral adipocytes. Human AT depots also differ in their intrinsic hematopoeitic stem cell activity of the stromal-vascular fraction (with that of visceral being lower than of subcutaneous), which may affect AT immuno-metabolism and inflammatory cell infiltration in obesity and diabetes.". Rough translation: not all fat tissue is created equal. Some of it seems to hurt your heart while some of it doesn't. Regardless, eating too much junk and sitting around all day definitely hurts your heart, while also making you fat, and to that extent, it might be simple enough for us, in practice, to figure that it's healthier to be reasonably lean, because some fat hurts us, and the lifestyle that make us fat hurts us.

But does that knowledge actually help? Does telling people that they're dangerously fat actually improve their lives and their health outcomes? Is this podcast likely to actually help anybody? Well, I think learning is an intrinsic good. In most situations, it's better to know a thing than it is to not know a thing.

But it is very doubtful that any education I might be doing in this hour of pod will result in anyone living a longer, healthier life. I'm looking at a 2020 study, "Self-perception of overweight and obesity: A review of mental and physical health outcomes," and I will boil it down thusly. Imagine two obese people with the same exact body composition, same exact lifestyle, same exact everything. All that's different is that one person self-identifies as obese, while the other person does not. The other person is blissfully unaware of their obesity.

The person who self-identifies as obese has

Measurably worse mental and physical health outcomes.

They die sooner, even though they're exactly the same.

They just know that they're obese.

The person who doesn't know that they're obese dies later. The authors of this study speculate their findings could be explained by social stigma — people living with the psychological stresses of being told they're fat, and being afraid to go to the doctor because the doctor is gonna say "you're fat.". At the broad population level, knowledge does not seem to help anything here, in part because nobody really knows how to help people lose weight over the long term, on the population level. Extraordinary individuals can do all kinds of extraordinary things, but most of us are, by definition, ordinary. And nobody knows how to help ordinary people keep off significant amounts of weight for significant durations of time. We don't even really know why people are getting so much fatter in the first place nowadays. Yeah, the core cause is probably economic development and greatly enhanced access to food, particularly cheap food consisting mostly of empty calories. But it might be a lot more complicated than that.

We may be hungrier than we used to be, because the kinds food we're eating and the amounts result in permanent cellular and hormonal changes that make us hungrier. All the people I know who study obesity tell me the same basic thing, which is the most promising avenue of research in obesity prevention is gut hormone research — manipulating hormones produced in our intestinal linings in response to what we eat that tell us how hungry we should be. Manipulate the gut hormones and you can lower people's appetite without giving them stimulants, which is what conventional diet pills are, and they raise your blood pressure, which defeats the entire point of losing weight, at least from a health perspective. Stimulant diet pills just replace one kind of stress on your cardiovascular system with another kind. In the content I make, I try to help people who want to lose weight lose weight. That is a goal you may have that I try to support, because it's a goal I have for myself. I don't want to carry any more adipose tissue than I'm carrying right now, because I've done it before and it just doesn't feel good. However, it is also true that most people probably can't lose a lot of weight and keep it off for a long time.

On the population level, none of the interventions work very well. What weight awareness mostly does is fill people with shame, and the shame hurts them. The body positivity movement is good. It's true that being very fat is probably very bad for you, and it is also true that helping people to be at peace with their obese bodies is probably good for them. These observations are not in conflict. Both of these observations are true according to the best empirical evidence we've got. When a jackass like Bill Marr or Jordan Peterson says "the body positivity movement is terrible, it's making people sicker because it’s justifying gluttony" he is wrong. That argument simply conflicts with the best available science.

Body positivity is good. Young people listening might take it for granted, but it's pretty amazing to me that now when you walk into a store, they have models and manikins modeling the clothing that actually look something like the customers who are probably gonna buy the clothing. When I was young you never saw big people modeling clothes for stores. I mean, I came of age in the 1990s so it was all "heroine chic," all the models were in the sub-18 BMI that's just as dangerous as being morbidly obese. We've got the bodies we've got, there's not much we can do about it, and so it's probably in the interest of everyone's long-term health that we just chill out and accept ourselves. This observation is not in conflict with the observation that being very fat is probably very bad for you. On the population level, I don't think any amount of good diet advice or exercise promotion is gonna fix the obesity problem. I only hold out hope for a pharmaceutical solution, and I think that solution is forthcoming.

There is a new generation of gut hormone-based appetite suppressants being tested right now, mostly in animals, that I think will fix the problem, perhaps even in our lifetime.

Once there are good, safe, non-stimulant appetite

Suppressing pills, i think most of us will simply be on them for most of our lives, and that's just fine.

That's great, actually. It's a simple adaptation we need to make to the conditions of modern life for which our bodies are not evolved, like brushing out teeth. Ancient humans didn't need to brush their teeth, because they didn't live that long. They didn't need their teeth to last 90 years. We do, so we brush our teeth. Ancient humans didn't need to suppress their appetite because they almost never had access to a large excess of food.

Now we do, so we need the pill. There's nothing wrong with pills, and this brings us back to blood pressure. One reason doctors tell you to lose weight is that fat people tend to have high blood pressure, and chronically high blood pressure is arguably the biggest single cause of preventable death in today's world. Does the fat tissue itself cause the high blood pressure, or does the lifestyle that makes you fat also, incidentally, raise your blood pressure? Good news: It doesn't matter anymore, because the latest generation of blood pressure pills is amazing, and most people can control their blood pressure now with an inexpensive pill with negligible side effects.

For god's sake, if you’re really hypertensive, just ask your doctor for pills. If your doctor says, "Why don't you try losing weight instead," I think you should say, "Well, why don't I try getting a new doctor instead?". There is no reason to live a single day with high blood pressure shredding your organs if you can just take a pill that stops it. Shaming people does nothing helpful, especially when it comes to people's most basic animal instincts, like the desire to eat, or the desire to breed.

Religion has tried for centuries to control sex by shaming people into not having it. How effective has that been? How well has that been working out? People have sex anyway, they just feel tons of shame about it. The shame might have the ancillary effect of sometimes making the sex extra hot, but that's not a good reason to shame people for having sex. The chief negative consequences of sex — unwanted pregnancy and sexually transmitted infections — these have been controlled so, so successfully in the developed world with pills and rubbers. Pills and rubbers and dams and diaphragms and such have worked the actual miracles that religion always promised but never delivered. Science beats religion, technology beats shame. I have faith in a technological solution to the obesity problem, which is a real problem. But shaming people for it is like shaming people for their other basic desires — it’s pointless and counterproductive.

Not even a wordsmith like Mr Steam can write an email harsh enough to shame me about my weight. I mean, I'll feel the shame for a little while, but eventually my big brain will triumph over my little brain, and I will say to myself, my BMI is 30 because I'm both strong and a little doughy. I'm a little doughy because I eat and drink a lot of delicious things and that's a trade off that I am 100% ok with. My blood work is great. But I'm starting to get old, and my blood work will probably start to look not so great pretty soon. I will try to respond by eating and drinking slightly fewer delicious things that are terrible for me. And I’ll keep moving my body regularly, mostly so that I don't get cranky and endanger my marriage as a result. Maybe I'll lose a little weight, maybe I won't.

Eliminating one should do far more for my blood pressure than any reasonable dietary change I could institute. Sorry I missed some releases last week, but like I said, the flu. Don't get the flu. It's the living worst. When people are like "Don't worry about Govid, it's just like the flu," remind them that the flu is incredibly bad and vast numbers of people are dying from it all the time. Anyway, make good choices. Stay as healthy as you reasonably can. Talk to you next time...