The big fat con story

Size really doesn't matter. You can be just as healthy if you're fat as you can if you're slender. And don't let the obesity 'experts' persuade you otherwise, argues Paul Campos

Paul Campos
Saturday April 24, 2004
The Guardian

In January 2003, as America prepared to go to war with Iraq, the US surgeon general, Richard Carmona, warned the nation that it faced a far more dangerous threat than Saddam Hussein's supposed weapons of mass destruction. Rather than focusing on the danger posed by nuclear, biological and chemical weapons, Carmona told his audience, "Let's look at a threat that is very real, and already here: obesity."

Carmona is merely the latest in a series of surgeon generals who have treated America's expanding waistline as the nation's leading public health problem. In doing so, they have merely reflected the language of much of the medical establishment, which for decades has treated "overweight" and "obesity" as major health risks.

Fat is on trial, but until now the defence has been mostly absent from the court of public opinion. At bottom, the case against fat rests on the claim that the thinner you are, the longer you will live. Fat Kills, and the prescription is clear: Get Thin.

The doctors and public health officials prosecuting the war on fat would have us believe that who is or isn't fat is a scientific question that can be answered by consulting something as crude as a body mass index chart (the BMI is a simple mathematical formula that puts people of different heights and weights on a single integrated scale). This, like so many other claims at the heart of the case against fat, is false. "Fat" is a cultural construct. According to the public health establishment's current BMI definitions, Brad Pitt, Michael Jordan and Mel Gibson are all "overweight", while Russell Crowe, George Clooney and baseball star Sammy Sosa are all "obese". According to America's fat police, if your BMI is over 25, then you are "overweight",full stop. Note also the radical difference between how our culture defines "fashionable" thinness for men and women. If Jennifer Aniston had the same BMI as her husband Brad Pitt, she would weigh approximately 55lb (nearly four stone) more than she does.

According to the latest BMI figures, 64.5% of American adults are either "overweight" (meaning they have a BMI of between 25 and 29.9) or "obese" (defined as a BMI of 30 or higher). Studies have found an association between even mild amounts of "overweight" and a significantly increased risk of premature death. For example, a highly publicised study published in the New England Journal of Medicine in 1995 found that women of average height who were as little as 12lb overweight had a 60% increased risk of mortality. A 1999 study published in the Journal of the American Medical Association estimated that overweight lead to around 300,000 premature deaths per year in America alone.

Meanwhile, the proportion of the population that maintains a dangerously high weight continues to climb: obesity in America has increased by more than 50% over the course of the past decade. If the authors of these studies are correct, America is facing a health crisis that, in the words of one anti-fat warrior, will make Aids look "like a bad case of the flu".

The Centres for Disease Control warn that overweight and obesity put persons at increased risk for congestive heart failure, coronary heart disease, diabetes, high blood pressure, obstructive sleep apnoea and other respiratory problems, and some cancers. The case against fat thus seems clear: having a BMI of 25 (this is a weight of 10 and a half stone for a woman of average height, and 12 and a half stone for a man of average height) or higher has been proven by medical science to cause a myriad of deadly conditions. The question then becomes, what can we do about this epidemic that is putting in jeopardy the lives of the more than 135 million adult Americans who are currently overweight?

The solution to this crisis seems obvious: Americans should find a way to weigh less. A recent article by Harvard Medical School researchers was more specific: "Adults should try to maintain a body mass index between 18.5 and 21.9 to minimise their risk of disease" (for an average-height woman, this would mean maintaining a weight between seven and a half and nine stone).

How are Americans supposed to achieve these goals? Public health authorities assure us that the best path to healthy weight loss is a combination of caloric restriction - aka dieting - and exercise. Unfortunately, this classic prescription has an extremely high failure rate: the vast majority of dieters end up regaining all of the weight they lose, and many end up weighing more than they did prior to their attempts to lose weight. Given this record of failure, it's not surprising that the pharmaceutical industry has spent billions of dollars attempting to develop safe and effective weight-loss drugs. And for those whom neither dieting nor diet drugs can seem to help, weight-loss surgery is becoming an increasingly popular, if dangerous, option.

This, then, is the case against fat: America, we are told, is on the verge of eating itself to death. The core belief of those prosecuting this case is that the BMI tables testify to a strong, predictable relationship between increasing weight and increasing mortality. That, after all, is what most people assume when they read that medical and public health authorities have determined a BMI of 25 or above is hazardous to a person's health. This belief, however, is not supported by the available evidence.

A 1996 project undertaken by scientists at the National Centre for Health Statistics and Cornell University analysed the data from dozens of previous studies, involving a total of more than 600,000 subjects with up to a 30-year follow-up. Among non-smoking white men, the lowest mortality rate was found among those with a BMI between 23 and 29, which means that a large majority of the men who lived longest were "overweight" according to government guidelines. The mortality rate for white men in the supposedly ideal range of 19 to 21 was the same as that for those in the 29 to 31 range (most of whom would be defined now as "obese"). In regard to non-smoking white women, the study's conclusions were even more striking: the BMI range correlating with the lowest mortality rate was extremely broad, from around 18 to 32, meaning a woman of average height could weigh anywhere within an 80-pound range without seeing any statistically significant change in her risk of premature death.

In almost all large-scale epidemiological studies, little or no correlation between weight and health can be found for a large majority of the population - and indeed what correlation does exist suggests that it is more dangerous to be just a few pounds "underweight" than dozens of pounds "overweight". So, let us look at the most cited studies for the proposition that "overweight" is a deadly epidemic in America today. Anyone who bothers to examine the evidence in the case against fat with a critical eye will be struck by the radical disconnect between the data in these studies and the conclusions their authors reach.

Annual Deaths Attributable To Obesity In The United States, which appeared in the Journal Of The American Medical Association (Jama) in 1999, is the source for the endlessly repeated statistic that overweight causes around 300,000 extra deaths in the US every year. (This "fact" has been cited in the major media more than 1,700 times in the past two years alone.) Look at these figures more closely. As Glenn Gaesser, a professor at the University of Virginia points out, studies have consistently failed to find any correlation between increasing BMI and higher mortality in people 65 and over, and 78% of the approximately 2.3 million annual deaths in the US occur among people who are at least 65. Thus, 78% of all deaths lack even the beginning of a statistical link with BMI. "That leaves 500,000 annual deaths in persons under 65 that might be related to BMI," Gaesser told me. "These include deaths from every possible cause: motor vehicle and other accidents, homicides, suicides, cigarettes, alcohol, microbial agents, toxic agents, drug abuse, etc, etc. To think that 60% [ie, 300,000] of these deaths are due to body fat is absolutely preposterous."

Overweight, Obesity And Mortality From Cancer, published in the New England Journal of Medicine in April 2003, was the subject of front-page stories in many of the nation's leading newspapers. For example, a Los Angeles Times article reported that the study provided "the first definitive account of the relationship between obesity and cancer". The article went on to quote the study's authors to the effect that perhaps as many as 90,000 deaths a year from cancer could be avoided if all adults maintained a BMI below 25 throughout their lives. The disjunction between this study's actual data and the alarmist headlines its authors helped generate is especially remarkable.

Among supposedly "ideal weight" individuals (BMI 18.5 to 24.9), the study observed a mortality rate from cancer of 4.5 deaths for every 1,000 subjects. Among "overweight" individuals (BMI 25 to 29.9 - a category that currently includes about twice as many adult Americans as the "ideal weight" cohort), the cancer mortality rate was 4.4 deaths for every 1,000 subjects. In other words, "overweight" people actually had a lower overall cancer mortality rate than "ideal weight" individuals.

Most Americans, and indeed most doctors, simply assume that the heavier you are, the more likely it is you will suffer from coronary artery disease - hence the various clichés about "artery-clogging" fast food and the like. Yet several studies have specifically investigated the question of whether a high percentage of body fat correlates with the incidence of coronary artery disease. Answer: no, it does not. Even massively obese men and women do not appear to be more prone to vascular disease than average.

It is true that increasing weight is associated with high blood pressure and certain types of heart disease. But even here there is considerable evidence that this correlation is not necessarily a product of being fat, but rather of losing and then regaining weight. Obese patients who have been put on very low-calorie diets subsequently display much higher rates of congestive heart failure than equally fat people who did not attempt to lose weight in the first place. The biggest evidentiary problem for those who insist there is a strong causal link between increasing weight and heart disease is that deaths from heart disease have been plunging at precisely the same time that obesity rates have been skyrocketing.

Indictments in the case against fat invariably focus on diabetes, because Type 2 diabetes is much more common among heavier-than-average people. It has become routine to claim that America is about to be overwhelmed by a diabetes epidemic, that for the first time Type 2 diabetes is being seen among children, etc, and that the solution to this crisis is to make fat people thin. Actually, the definition of diabetes has changed (from a fasting blood sugar of 140 to a blood sugar of 126) and many more people have been diagnosed as suffering from the disease. Several recent studies indicate that the key to avoiding Type 2 diabetes is not to try to lose weight (indeed, there is much evidence that dieters are far more prone to the disease than average), but rather to make lifestyle changes in regard to activity levels and dietary content that greatly reduce the risk of contracting the disease, whether or not such changes lead to any weight loss.

Over the past three decades, according to Gaesser's survey of the literature, between 35 and 40 medical studies have found increasing body mass to be associated with a lower incidence of various cancers. Other diseases and syndromes that various medical studies indicate are less common among heavier people include emphysema, chronic obstructive pulmonary disease, hip fracture, vertebral fracture, tuberculosis, anaemia, peptic ulcer and chronic bronchitis, among others. Indeed, how many people are aware that heavier women have much lower rates of osteoporosis, which is a very common and serious condition among older women? Consider the potential implications for public health of the fact that hip fractures are two and a half times less likely to occur among heavier women. Hip fracture is a leading cause of both death and permanent disability among older women (in Great Britain, more women die from osteoporosis-related hip fracture than from breast, cervical and uterine cancer combined).

If we were to employ the logic of the anti-fat warriors, does this mean that we should be encouraged to gain weight so as to protect ourselves from, among other things, cancer, osteoporosis and most of the major pulmonary diseases?

There are some groups of heavier individuals -usually those with BMI figures in the mid-30s and above - who do suffer from worse health than those of "ideal-weight". Yet this does not of itself prove that such people's problems are caused by their excess weight. There are many other factors that disproportionately affect the heaviest people in our society, and that also correlate with poor health: most notably a sedentary lifestyle, poor diet, dieting-induced weight fluctuation, diet drug use, poverty, access to and discrimination in health care, and social discrimination generally. None of these factors was taken into account in Annual Deaths Attributable To Obesity In The United States, the Jama study responsible for the "fact" that fat kills 300,000 Americans a year.

The case against fat proceeds on the assumption that if a fat person becomes thin, that person will acquire the health characteristics of people who were thin in the first place. Although this assumption may seem like simple common sense, it is, like many commonsensical assumptions, quite dubious. If a person who is physiologically inclined to be fat loses weight, this does not transform that person into someone who is physiologically inclined to be thin. To understand the implications of this distinction, consider that bald men die sooner, on average, than hirsute men, probably because bald men have higher levels of testosterone, which appear to lower life expectancy. Given this, surely no one would conclude that giving a bald man hair implants would improve his prospects for long life.

No one has ever successfully conducted a study into the effects of long-term weight loss, and for a very simple reason: no one knows how to turn fat people into thin people.

This statement is in one sense shocking, despite the fact that there are few better established empirical propositions in the entire field of medicine. How can this be? After all, as those who prosecute the case against fat never cease to remind us, everyone knows how to lose weight: eat less and exercise more. In theory, this regimen should make people thin. In practice, it does not.

More Americans than ever are dieting, percentages tripled over the course of the last generation. And the result? Americans weigh on average 15lb more than they did 20 years ago. Tens of millions of Americans are trying - more or less constantly - to lose 20 or 30lb (25lb tends to be the average figure cited in surveys of dieters). If you ask them why, most will tell you that they are doing so for the sake of their health, often on the advice of their doctors. Yet Gaesser notes that more than two dozen studies have found that weight loss of this magnitude (and indeed of even as little as 10lb) leads to an increased risk of premature death, sometimes by an order of several hundred percent.

Over the past 20 years, scientists have gathered a wealth of evidence indicating that cardiovascular and metabolic fitness, and the activity levels that promote such fitness, are far more important predictors of both overall health and mortality risk than weight. Yet none of the studies most often cited for the proposition that fat kills makes any serious attempt to control for these variables.

The most extensive work of this sort has been carried out by Steven Blair and his colleagues at Dallas's Cooper Institute, involving more than 70,000 people. What they have discovered is that, quite simply, when researchers take into account the activity levels and resulting fitness of the people being studied, body mass appears to have no relevance to health whatsoever. In Blair's studies, obese people who engage in at least moderate levels of physical activity have around one half the mortality rate of sedentary people who maintain supposedly ideal weight levels.

Similarly, a 1999 Cooper Institute study involving 22,000 men found the highest death rate among sedentary men with waist measurements under 34 inches, while the lowest death rate was found among fit men with waist measurements of 40 inches or more. A 1995 Blair study found that improved fitness (ie, going from "unfit" to "fit"), with the latter requiring a level of exercise equivalent to going for a brisk half-hour walk four or five times per week, reduced subsequent mortality rates by 50%. As Blair himself puts it, Americans have "a misdirected obsession with weight and weight loss. The focus is all wrong. It's fitness that is the key."

Why are Americans so afraid of the generally small health risks associated with above-average weight, while remaining comparatively indifferent to the much larger health risks associated with being a man, or poor, or black, or unusually thin?

Consider this: from the perspective of a profit-maximising medical and pharmaceutical industry, the ideal disease would be one that never killed those who suffered from it, that could not be treated effectively, and that doctors and their patients would nevertheless insist on treating anyway. Luckily for it, the American health care industry has discovered (or rather invented) just such a disease. It is called "obesity". Basically, obesity research in America is funded by the diet and drug industry - that is, the economic actors who have the most to gain from the conclusion that being fat is a disease that requires aggressive treatment. Many researchers have direct financial relationships with the companies whose products they are evaluating.

Government grant money is scarce, and the process for securing it extremely competitive. "When you apply for a grant," one prominent obesity researcher told me, "you have to make a strong case for funding by explaining the significance of the research." The researcher then asked me which of the following scenarios was most likely to produce a successful application:

1 "Though it is difficult to establish the independent contribution of obesity to morbidity and mortality, and it appears that lifestyle factors - such as poor diet and lack of physical activity - pose far greater health risks, we nevertheless request funding to study obesity as a matter of scientific curiosity, and also to assess whether it might be more prudent to get fat people fit rather than to get them thin."

Or: 2 "Obesity kills at least 300,000 Americans every year, and mathematical models of the obesity epidemic predict that within 50 years every man, woman and child in America will be overweight or obese."

In West Africa today, beauty pageants feature contestants who would be considered markedly "obese" in the US; many of the young women who represent the pinnacle of female beauty in these cultures weigh more than 14 stone. In this regard, contemporary West Africa is quite similar to the US in the 1890s, when the 14-stone actress Lillian Russell was considered the undisputed beauty of her time. Historically speaking, far more cultures have mirrored contemporary West Africa and America in the latter half of the 19th century than have resembled the US today, where an almost unprecedented ideal of thinness reigns supreme.

This is a culture whose need to control the world and the people in it is so intense that it has been driven to the preposterous conclusion that millions of unique individuals should all weigh within 10lb of an imaginary ideal weight. In fact, as we have seen, there is no valid medical reason why two women of the same height cannot weigh seven and 14 stone respectively, while both maintain optimum cardiovascular and metabolic fitness, and excellent overall health. However, there are enormously powerful cultural, political and economic forces that ensure we do our best to make sure one of these women will remain miserable about her "disease".

If one were forced to come up with a six-word explanation for the otherwise inexplicable ferocity of America's war on fat, it would be this: Americans think being fat is disgusting. Fifty years ago, America was full of people that the social elites could look upon with something approaching open disgust: blacks in particular, of course, but also other ethnic minorities, the poor, women, Jews, homosexuals, and so on. Nowadays, a new target is required.

As The Handbook Of Obesity Studies notes, "In heterogeneous and affluent societies such as the United States, there is a strong inverse correlation of social class and obesity, particularly for females." In other words, on average, poor people in America are fat and rich people are thin. The disgust the thin upper classes feel for the fat lower classes has nothing to do with mortality statistics and everything to do with feelings of moral superiority. Precisely because Americans are so repressed about class issues, the disgust the (relatively) poor engender in the (relatively) rich must be projected on to some other distinguishing characteristic.

In 1853, an upper-class Englishman could be quite unselfconscious about the fact that the mere sight of the urban proletariat disgusted him. In 2003, any upper-class white American liberal would be horrified to imagine that the sight of, say, a lower-class Mexican-American woman going into a Wal-Mart might somehow elicit feelings of disgust in his otherwise properly sensitised soul. But the sight of a fat woman - make that an "obese" - better yet a "morbidly [sic] obese" woman going into Wal-Mart... ah, that is something else again.

The single most noxious line of argument in the literature about obesity is that black and Hispanic girls and women need to be "sensitised" to the "fact" that they have inappropriately positive feelings about their bodies. Readers may suspectthis is a bad joke: I wish it were. One University of Arizona study found that, while only 10% of the white teenage girls surveyed were happy with their bodies, 70% of the black teenage girls were happy with theirs (the black girls weighed more, on average, than the white girls).

When asked to define "beauty", the white girls described their feminine ideal as a woman 5ft 7in tall, weighing between seven and seven and a half stone (ie, someone thinner than the average model). By contrast, the black girls described a woman whose body included such features as visible hips and functional thighs.

Obesity researchers and diet companies are doing their best to change this unacceptable situation. In recent years, diet companies have targeted much of their advertising specifically toward upwardly mobile black and Hispanic women. As for obesity researchers, a recent article noted that black girls have better body images and lower rates of eating disorders than white girls, and also noted that they weighed more.

"These findings," the authors concluded, "should be used in the development of culturally sensitive public health intervention programmes to help reduce the high rates of obesity within the black community and encourage black youth to achieve a healthy and reasonable [sic] body size." Here again, we see how crucial the health justification remains to all aspects of the war on fat.

How would a proposal for "culturally sensitive public health intervention programmes" sound if it were translated (accurately) as a proposal to make black and Hispanic girls as neurotic about their weight as white girls tend to be, because these groups represent the best opportunity for expanding the market for the useless, expensive and dangerous products of the weight loss industry?

Thinness has a metaphorical significance in America today. Americans - and especially American elites - value thinness for precisely the same reason someone suffering from anorexia nervosa does: because not eating means not giving in to desire. Strangely, what the American elites consider most desirable is a body whose appearance signals a triumph of the will over desire itself. Thus, bodily virtue is not so much indicated by thinness per se, but rather by an achieved thinness. Ultimately the war on fat is both a cause and a consequence of the transformation of the Protestant work ethic into the American diet ethic.

The obesity myth thrives in contemporary America because America is an eating-disordered culture. Moreover, the prime symptoms of this situation - our increasing rates of "overweight", bbulimia and anorexia - are also symptoms of, and have become metaphors for, a broader set of cultural anxieties.

Americans worry, with good reason, that we have become too big for our own good: that we consume too much, too quickly; that our cars, our houses, and our shopping malls are too large; that our imperial ambitions to make the world safe for democracy and McDonald's are too grand. Under these circumstances, obsessing about the 10lb of "extra" weight that the average American adult has gained over the past 15 years has become a convenient way of avoiding a more direct engagement with any number of issues regarding America's excesses.

For upper-class Americans in particular, it's easier to deal with anxiety about excessive consumption by obsessing about weight, rather than by actually confronting far more serious threats to our social and political health. We may drive environmentally insane SUVs that dump untold tonnes of hydrocarbons into the atmosphere; we may consume a vastly disproportionate share of the world's diminishing natural resources; we may support a foreign policy that consists of throwing America's military weight around without regard to objections from our allies - but at least we don't eat that extra cookie when it's offered to us

· This is an edited extract from The Obesity Myth: Why America's Obsession With Weight Is Hazardous To Your Health, by Paul Cosmos, to be published next month in the US by Gotham Books.