Redefining Wellness: A Doctor's Reflection on the Transient Nature of Metabolically Healthy Obesity

I cock my head at my “new” patient, Sherri, heading into my consultation room at 8:30 am on a rainy Monday morning. She looks vaguely familiar, but I can’t quite place her face. Dr. Messer, she cries, don’t you remember me? I was one of your very first patients fifteen years ago in Westchester. You had just finished training.” Suddenly it all comes back to me.

The experience of meeting Sherri reminded me of the lesson in humility my mentor, Dr. Alice Levine, taught our crowded lecture hall so many years ago. Once upon a time, she prided herself on being an infinitely important doctor. One day, she met a patient with empty Sella syndrome (literally missing his whole pituitary gland-MRI proven).  She fully expected to swoop in to save the patient’s life by expertly replacing each absconded pituitary hormone – but to her shock and delight, an invisible little sliver of pituitary left in his brain allowed him to magically eek out completely normal hormone levels.

Sherri walked into my office so many years ago with a body mass index in the mid 40s. In laymen’s terms, she was morbidly obese. I settled in to discuss her hypertension, diabetes, high cholesterol, fatty liver, polycystic ovary syndrome, etc. – but to my shock and delight, her blood pressure and blood work were completely normal, and I struggled to keep a neutral face. She was there to discuss hair loss. I had just met my first patient with metabolically healthy obesity (MHO), and I was floored.

Fast forward 15 years, Sherri sits down across the desk from me and hands me her bloodwork. Her formerly pristine labs are now peppered with red exclamation points and critically high lab values. Sherri had transitioned from MHO to metabolically unhealthy obesity (MUO).

Early clinical trials concluded that it was possible to be obese but metabolically healthy.

Approximately 15% of patients living with obesity lack any of the co-morbidities typically associated with this phenotype. These findings contributed to the de-emphasis on obesity as a true disease state. In retrospect, the MHO subtype appears to be much more common in the younger and more active population and is typically quite transient. A new study published in Diabetes, Obesity and Metabolism revealed that people with MHO are 1.5 times more likely to develop diabetes than metabolically healthy normal weight individuals. In addition, people living with obesity and no known metabolic complications still had a 50% higher risk of coronary artery disease. The study also showed that over 50% of people initially characterized as MHO eventually became MUO after the follow up period of 16 years.

So once again, all roads lead to Wegovy. Sherri’s nearly inevitable transition from MHO to MUO speaks to the pressing need to treat patients living with obesity before the metabolic complications and increased cardiovascular risk develop. Fifteen years ago I discussed her hair loss for 45 minutes and never mentioned the elephant in the room. Of course, there was no Wegovy, Ozempic or Mounjaro back then. Now that we have the tools we need, let’s commit to helping our patients achieve true metabolic health. Unlike the magical pituitary patient, metabolically healthy obesity is an illusion – and we owe it to our patients to treat it as such.