Author(s): Amanda Sainsbury[sup.1] and Phillipa Hay[sup.2,3] The argument for an urgent rethink When I (AS) was a child, my grandmother used to say Don't pull an ugly face, because if the wind changes, your face will become stuck like that. I don't know what evidence my grandmother had for this advice, but as a neuroscientist who studies the effects of diet on the hypothalamic control of appetite and body weight, I say Don't eat an ugly diet or let yourself stay fat, because if the wind changes you may become stuck with permanent obesity. The long-term effects of excess calories and adiposity on body weight regulation appear to have been overlooked in the fat acceptance movement that has emerged in parallel with the obesity epidemic. In this commentary I outline the possibility that excess body fat and its underlying contributors lead to permanent changes in the brain pathways that control body weight, and call for urgent reconsideration of the 'health at every size' concept. While I certainly agree that it is possible to have healthy behaviours that provide health benefits at a wide variety of body sizes, I disagree that it is possible to be - or to stay - truly healthy at every size. The World Health Organisation decrees that a body mass index (BMI) of 18.5 to 24.9 kg/m[sup.2] is generally optimum for health, at least for Caucasians between the ages of 18 and 65 [1]. However, there are many people who are healthy who have a BMI outside this range. For instance, some people self-impose long-term calorie restriction and generally have a low BMI and exhibit metabolic benefits, in keeping with animal studies which show that long-term calorie restriction prolongs life [2]. There are also people with a BMI in the overweight ([greater than or equai to] 25 kg/m[sup.2]) or obese ([greater than or equai to] 30 kg/m[sup.2]) range that exhibit no signs of eminent metabolic disease whatsoever, and these are not limited to people who are body builders or elite athletes [3]. Moreover, overweight or obese people who lose as little as 5-10% of their body weight exhibit significant health gains, even if their BMI remains in the overweight or obese range. Examples include improved fertility and pregnancy outcomes [4], moderate to large clinical improvements in osteoarthritic joint pain [5], and a markedly reduced likelihood of progression to type 2 diabetes mellitus [6]. Indeed, without losing any weight at all, substantial health gains can be achieved through better diet and exercise in overweight or obese people [7]. Despite the above evidence that it certainly is possible to be healthy - or to gain health benefits - at a wide variety of BMIs, there is a large body of evidence that having a BMI outside certain limits increase the risk of health problems, hence the WHO recommendations. In general, a low BMI - an indicator of malnutrition - is associated with poor health outcomes. While the exact proportion of obese people who are metabolically healthy varies depending on what criteria are used to define both obesity and health, it is smaller than the proportion of obese people who are not metabolically healthy [3]. As it is currently not possible to predict which people will remain metabolically healthy despite excessive weight gain, it may be dangerous to make blanket community statements that people can have health at every size. Moreover, recent research suggests that even for obese people who are metabolically healthy, it is only a question of time before a variety of issues raise their heads, contributing to significantly greater mortality from cardiovascular disease and all other causes [8]. Whether or not a person with excess weight develops metabolic diseases such as diabetes or cardiovascular disease, sooner or later the mechanical effects of excess weight and the resultant gait abnormalities, combined with systemic inflammation, are likely to take a toll. As one example, adults who are overweight have a 2. …
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