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Can you be healthy at any size?

The rising fat-acceptance movement says being overweight isn't necessarily bad for you —and some doctors agree. Other experts contend that's a dangerous, even irresponsible, point of view.
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Oscar-winning actress Mo'Nique likely has a BMI in the "obese" range, but she recently lost 42 pounds and exercises regularly. "Everybody can't be a size zero," she has said. "But let's be healthy, big people."ROBYN BECK / AFP - Getty Images
/ Source: Womens Health

Tyra Banks has a new mission: Cast an unlikely group of aspiring models — namely, those whose curves can fill out a size 14 — for a plus-size competition. "Plus-size is really the average American woman," Banks has said. "And that woman is healthy." That woman is also, says the Centers for Disease Control and Prevention, more than 20 pounds overweight.

In fact, a growing collective of doctors and activists have begun to argue that lifestyle and genetics are what determine a woman's health. Even our new (zaftig) surgeon general, Regina Benjamin, M.D., recently said, "Being healthy is not about a dress size."

That's hopeful news for the 33 percent of Americans who are overweight (this doesn't include the 34 percent who are obese). It's also news a rival camp of experts isn't buying. Any equating of "overweight" and "healthy" is irresponsible, they say. Especially in a nation where health-care costs have skyrocketed, due in part to the rising rates of illnesses linked to excess pounds.

The case for healthy fat
For Crystal Renn, bulking up has felt nothing but great. The formerly 95-pound model was once depressed, living on little besides veggies and diet soda. Today, she's forever running between editorial shoots and runway gigs. "The caliber of work I do is much higher now that I have energy," Renn says. She certainly looks healthier, but at 5'9" and 170 pounds, she's overweight — at least according to her body mass index (BMI).

Doctors have long used BMI to measure whether a patient is at a healthy weight. Anyone scoring above "normal" has been regarded as potentially unwell. But compelling new research shows otherwise, says Paul Campos, author of "The Obesity Myth: Why America's Obsession with Weight Is Hazardous to Your Health." "The correlation between weight and health is greatly exaggerated," he says, pointing to studies that found people with an "overweight" BMI have lower incidence of lung cancer, chronic bronchitis, anemia, and osteoporosis than their thinner peers. (Being heavier helps fend off osteoporosis, for example, because a little extra mass helps strengthen bones.)

What's more, a long-term study published in the journal Obesity found that people with "overweight" BMI scores have a lower risk of mortality than any other weight group.

So, hooray for a little junk in the trunk? Yes, some fat can be beneficial, says Konstantinos Manolopoulos, an Oxford University researcher. Pear-shaped women can — finally! — rejoice: Thigh, hip, and butt fat is chemically very stable, and stable fat traps harmful compounds released during digestion. Thigh fat also secretes adiponectin, which helps the body metabolize sugar, and leptin, which regulates appetite.

Fortified by such science, the fat-acceptance movement pushes another key point: Extra weight may not be ideal, but it sure beats dieting. Research shows extreme yo-yo dieting can, over time, slow metabolism and cause cardiac stress; it can even lead to long-term weight increases.

Just ask fat-acceptance activist Kate Harding, co-author of "Lessons from the Fat-o-Sphere: Quit Dieting and Declare a Truce with Your Body," who twice lost more than 20 percent of her weight — only to regain it. It left her wondering, What if trying so hard not to be fat is actually a bigger health problem than being fat?

The case against healthy fat
There's no chance dieting is worse, says the anti-fat-acceptance camp. Weight loss may be difficult, but it's still worth pursuing in the name of health. Some research shows that extra weight can increase your risk of developing breast cancer. And overweight women with normal cholesterol and blood pressure levels can still go on to develop heart disease at higher rates, says Barbara Berkeley, M.D., director of weight-management services at the Lakehealth System in Cleveland. "In other words, being overweight may look 'healthy' but probably isn't once we follow someone over a period of years," she says. (But what about those studies that show overweight people live longer and avoid a whole host of diseases? Berkeley argues that the overweight seem to fare better because very underweight people do worse and throw the curve.)

Then there's that question of fat placement. When you gain weight through overeating, you can't control where the pounds land. Thigh fat might be beneficial, but abdominal fat is not. Nor is dangerous visceral fat, which infiltrates and coats your organs like candle-wax drippings, releasing inflammatory fatty acids that have been linked to cancer and coronary diseases.

And weight gain can be a slippery slope. In Berkeley's practice, she sees plenty of patients who have let mere love handles escalate into a heaviness that shames them away from the gym or doctor's office. So she opposes any endorsement of being overweight, and maintains that humans, who once had to hunt and gather to survive, evolved to be a lean species.

She's not alone. Lincoln University recently made headlines when the school set up BMI score graduation requirements: Not under 30? No diploma. (Following a public outcry, the university rescinded the rule.)

Both Alabama and North Carolina announced they will charge fat state employees an additional monthly fee for health care. And mega-green grocer Whole Foods started up a voluntary employee incentive program — one based, in part, on workers' weights. The lower their BMI, the bigger their discounts.

After all, explains Berkeley, "Your heart is only as big as your fist," and asking a small muscle to power an overweight frame is "like putting a little engine in an SUV."

Beyond BMI
If the two sides were to agree on anything, it would be this: Fitness is key, and pounds matter less than type of body fat. "Recently, there have been efforts to look beyond BMI," says Margaret Lewin, M.D., clinical assistant professor at Cornell University's Weill Medical College.

The old-school measurement does serve a purpose, but its shortcomings are clear. On her blog, Shapely Prose, activist Harding runs a "BMI project," a series of photos of people of different sizes accompanied by their BMI labels. They range from "underweight" to "morbidly obese," but for the most part they look, well, pretty normal. Last is a shot of the seemingly healthy Harding, balanced on her hands in the crow yoga pose. Her BMI category? "Obese."

Exercise, everyone concurs, is crucial. It reduces mortality risk by a whopping 50 percent, regardless of weight, says Steven Blair, P.E.D., professor at the University of South Carolina. Aerobic exercise and resistance training attack waistline fat, both the padding you can see and the visceral stuff you can't. Scientists have even found that working out prevents the latter from forming in the first place. In fact, between a plus-size gymgoer and a thin couch potato, the bigger girl is better off, says Blair, and less likely to develop weight-related illnesses. That's something to hold on to as the fat-acceptance argument roils. Whether or not extra girth is indeed healthy, everyone should be active.

Speaking recently on the "Ellen DeGeneres Show," Oscar-winning actress Mo'Nique recounted the moment she decided to shape up. The fat-pride supporter was standing nude before a mirror when her husband asked her how much she weighed. The answer: 262 pounds. "He said, 'Mama, that's too much. I want you for a lifetime,' " she recalled. She has since lost 40 pounds. She's certainly not thin — her BMI is likely in the "obese" range — but she's working on that visceral fat with exercise. "Everybody can't be a size zero," she has said. "But let's be healthy, big people."