Daniel Lambert weighed 56 stone, yet he was considered to be the fittest specimen of humanity, right up to his death at age 33 in The Waggon and Horses pub in Stamford in 1809. “It was impossible to behold his excessive corpulence without being astonished that he was not suffocated by such an accumulation of fat” (Haslam and Haslam, 2009). Perhaps some undiagnosed underlying condition was the cause of his premature demise?
The obesity paradox suggests that some individuals with heart failure or renal disease are somehow protected against mortality by their excess weight (Curtis et al, 2005), in the same way that an obese Victorian solicitor would consider that his expensive diet and lifestyle awarded him protection against cholera and tuberculosis.
Aung et al’s (2014; summarised alongside) data adds to the “fit but fat” debate, suggesting that metabolically healthy obese people have an increased risk of cardiovascular (CV) disease and diabetes, but so do metabolically unhealthy lean individuals. Their work builds on past findings that, while <30% of obese individuals may be metabolically healthy (Blüher, 2012; Hamer and Stamatakis, 2012), some 6.2% of women and 4.6% of men of normal weight have >3 features of the metabolic syndrome (Park et al, 2003).
These findings suggest that the “fat but fit” phenotype is, in a significant proportion of individuals, only a transient phenomenon prior to the emergence of illness – as in Daniel Lambert’s case. Thus, Aung et al do not suggest that obese individuals might be spared treatment, but rather that non-obese people who are metabolically unfit should be managed as if they were obese. For this reason, population-level screening for metabolic dysregulation is crucial.
I agree with Aung et al that screening for, and management of, metabolic disturbances should be routine in clinical practice. Despite this, some so-called “experts” in the UK have resisted calls for screening, placing hundreds of thousands of people at risk of avoidable vascular damage. After all, raised blood pressure and lipids are generally asymptomatic, as, very often, is diabetes.
Reasons for failure to introduce screening programmes in the UK have included not wanting to stigmatise people by labelling them as “diabetic”, or that the NHS can not afford to provide care for the 850 000 people with undiagnosed diabetes (Diabetes UK, 2012). It is unsurprising then that as many as 40% of people already have established microvascular complications at the time of diabetes diagnosis (Spijkerman et al, 2003). We can do more for these patients than allow them to remain unscreened and suffering unnecessary vascular damage.
To view the summaries of each paper, please download the PDF of this article.
