At 5-foot-4 and 190 pounds, Jude Mathews would seem to personify the health crisis facing a nation in the throes of an obesity epidemic. But the librarian from Evanston, Ill., begs to differ.
"My blood pressure is rock solid. My cholesterol numbers are basically fine. My doctors don't see anything they say I need to worry about," said Mathews, who is 55, exercises regularly and eats a well-balanced diet. "One little number on the scale is not all there is to your health."
As medical authorities have become increasingly alarmed by the rapidly rising number of Americans who are overweight and obese, people such as Mathews find themselves at the center of an intense debate: Can people be overweight but still healthy?
Challenging conventional wisdom
In books, in medical journals and at public health conferences, scientists have been dueling over the relative importance of fatness vs. fitness, and whether there is any common ground between the two camps. A small but vocal cadre of researchers has been challenging conventional wisdom, arguing that not only is it possible to be both fat and fit, but fitness is actually more important for health.
"All too often, medical professionals say it's the obesity we have to cure. That's the be-all and end-all. It's not," said Steven N. Blair, who heads the Cooper Institute, a Dallas research foundation focused on physical activity. "The impression is that everyone who is overweight faces an elevated risk for mortality. That's simply not true."
Other experts, however, maintain that while there may be exceptions, the evidence is clear for most people: Being overweight significantly increases the risk of a host of debilitating and often deadly health problems, including heart attacks, strokes, cancer and diabetes.
"Being overweight has a clear association with important health problems, and even modest weight loss has important health benefits," said Walter Willett, an expert on nutrition and health at the Harvard School of Public Health. "To tell people it doesn't matter is really misleading. It does make a difference. It makes a huge difference."
'Clear risk factor'
Playing down the risks of excess weight is dangerous, Willett and others say, particularly with two-thirds of Americans already overweight, including one-third who are officially obese.
"I would not want to switch the emphasis away from trying to control weight," said Lawrence J. Cheskin, director of the Johns Hopkins Weight Management Center. "That's a clear risk factor."
Blair and other fitness proponents acknowledge that some overweight people are at increased risk for health problems, and that many people may benefit from losing weight. But they argue that society focuses far too much on dropping pounds and far too little on exercise, eating well and being physically fit.
"I don't believe height and weight is a good indication of health," said Joanne Ikeda, co-director of the Center for Weight and Health at the University of California at Berkeley. "If a fat person or obese person has normal blood pressure, if their total cholesterol and glucose levels are normal and they are healthy, there is no reason they should necessarily have to lose weight."
Many people are simply born to be bigger, which does not necessarily mean they are destined to have health problems because of their weight, especially if they exercise regularly and eat well, she said.
"There is a subset of people who are meant to be large people," Ikeda said. "If they are in fact 'obese' but they are metabolically healthy, their bodies are constructed in a way that carrying a large amount of weight is not deleterious."
Fitter, not necessarily thinner
The increased health risks blamed on being overweight are really the result of many overweight people being out of shape and having poor diets and other unhealthful habits, Blair and others say. If those factors are considered, studies have found that any increased risk virtually disappears, they say.
"We've studied this from many perspectives in women and in men and we get the same answer: It's not the obesity -- it's the fitness," Blair said. "Fitness can substantially reduce, if not eliminate, the high risk of being obese."
Ikeda tests people to see if they are "metabolically healthy." If she spots warning signs, she recommends exercise and a nutritious diet, but with the goal of making people fitter, not necessarily thinner.
"What weight-loss programs promote are diets that are so low in calories that people are constantly fatigued, and then they have a hard time getting out there to exercise, which is really what will help them," Ikeda said. "How stupid is that?"
The focus on weight loss is especially misguided because most people simply are unable to lose substantial weight and keep it off, Ikeda, Blair and others say.
"I'm a short, fat guy myself," Blair said. "I'd like to be thinner. I'm not saying people shouldn't try to lose weight. But we're not getting anywhere with all the focus on obesity -- shouting from the rooftops how bad obesity is. So if the strategy is not working, it seems to me we ought to be thinking about different strategies."
Becoming fit is often much more attainable, Blair and others say.
"If you take a fat person who has all these health problems that have been labeled weight-related health problems and put them on an exercise program and clean up their diet, their health generally improves yet their body weight hasn't budged much," said Glenn A. Gaesser, a University of Virginia physiologist who wrote "Big Fat Lies: The Truth About Your Weight and Your Health," a book that questions many assumptions about obesity. "It's far easier to get a fat person fit than to get a fat person thin."
Mathews, the Illinois librarian, takes dance, Pilates and tai chi classes several nights a week and lifts weights to stay fit, and watches what she eats to stay healthy.
"I wouldn't mind losing weight, but I know if I go on a weight-loss diet I'll just spring right back," Mathews said. "What is really dangerous is yo-yo dieting, not to mention destroying people's self-esteem."
The obsession with weight also risks prompting people to overreact, some say.
"We have yuppie parents putting their kids on diets just because they gain a few pounds," Ikeda said. "We see adolescent girls obsessed with obtaining the so-called ideal body image. We see people smoking, abusing laxatives and taking all sorts of extreme measures."
Another danger is that the emphasis on weight may be misleading thin people about their health.
"If someone is in what is considered the normal range, they think they don't have to exercise and can eat whatever they want," Gaesser said.
Obesity researchers disagree
Willett and others acknowledge that fitness is important and that overweight people benefit from exercise and eating better even without losing weight. But they argue that a careful analysis of many large studies has shown a clear, independent relationship between excess weight and increased risk for health problems.
"When you look at the data carefully, you find that people who are active and lean have the lowest mortality of all," Willett said.
And many obesity researchers take issue with the contention that most overweight people cannot lose weight.
"People can lose weight. They do lose weight," said Arthur Frank, a weight expert at George Washington University. "I've seen people who are indolent in their health habits and they lose weight and their blood pressure comes down and their cholesterol comes down and they feel wonderful, even without doing any exercise."
Willett is also concerned that turning the focus away from weight will keep people from being vigilant about preventing weight gain in the first place, which is the most effective strategy.
"One of the big problems is by the time people become overweight or obese it's very hard for them to become active. They've developed arthritis or other problems that makes it hard, which is why we have to pay attention to weight early on," Willett said.
Despite the intensity of the debate, Willett, Frank, Blair, Gaesser and others have been trying to find common ground, with each side emphasizing that the two ideas are not necessarily mutually exclusive. The best strategy would be to encourage people to exercise regularly and eat well. Some will lose weight, some won't, but all will benefit from getting as much exercise as possible and becoming more physically fit and possibly trimming down in the process.
"This is something that really shouldn't be a debate of one versus the other," Willett said. "It's clear that both fitness and fatness are important. It's definitely good to be as fit as possible no matter what your body weight. But it's also clear that it is optimum to be both lean and fit. It shouldn't be a question of one or the other."