Fat land : how Americans became the fattest people in the world (15 page)

This Blair used to attack U.S. weight guidelines, which he regarded as too restrictive. (The 1995 guidelines suggested that Americans maintain a healthy weight, preferably a BMI of 25 or under.) To sharpen his epidemiological blade, Blair did another study. This time he calculated in risk from cardiovascular disease. The results were again revealing. Fit but overweight men displayed a similar rate of mortality as physically fit men of normal weight. Almost as important, he proclaimed, fit overweight men had a lower risk for cardiovascular disease than unfit normal-weight men. This, of course, was a bit like comparing apples and oranges (or, more apt, apples and bananas); no one, after all, had ever said that being unfit and skinny was a good public health goal. But Blair saw fit to spin it like this: "The health benefits of

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normal weights appear to be limited to men who have moderate or high levels of cardiorespiratory fitness. These data suggest that the 1995 U.S. weight guidelines may be misleading. . . ." And again: "We do emphasize that increasing fitness may be more important than maintaining healthy weights."

The media translation was predictable. As the Associated Press (and many others) slugged it: "Study finds obese exercisers outlive thin people who don't." A book came out that was entitled You Don't Have to Be Thin to Win. The New York Times even went so far as to say that Blair had "dispelled" a "myth" that fat people could not be fit.

But that was never really the myth, and that was certainly not why body weight guidelines promoted leanness. Body weight guidelines — and the entire infrastructure of promoting weight loss — lay in long, deep, and convincing science that body weight is inversely related to health. Over and over, studies show: The fatter you are, the more likely you are to be sick, feel sick, and die young. Blair's own data are a case in point. Taking out the fitness variable and looking at body weight only, Blair admitted: "Men with a BMI of >30 were generally less physically fit and had more unfavorable risk factors than men in the lower BMI groups." Lower weight men had higher good cholesterol, lower bad cholesterol, and higher treadmill times than fatter men. "The highest death rate," he added, "was observed among those men in the highest BMI category and correspondingly lower death rates were observed in each subsequently lower BMI category." And when one looks at the difference between low fit men in all categories — which one might think would be useful since most obese people are not fit — Blair's upbeat message fades: Normal weight nonfit men had an age-adjusted death rate (the number of excess deaths in the studied group) of 52.1; unfit fat men had the higher rate of 62.1. More: Unfit lean men were half as likely to have a history of hypertension than unfit fat men. In the real world, even according to Blairism, the fat are more likely to die early — and to live precariously — than the lean.

Now look at the fat fit vs. the lean fit in Blair's population. In

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almost every category, it is better — far better — to be lean. Consider treadmill time. The data are unequivocal: As a person gets fatter, even if he is getting technically fitter, he is also less likely to perform as well on the treadmill test as his leaner brothers. Blair admitted: "Men who were normal weight and physically fit had the longest average treadmill time."

But the single most important fact — again detailed by Blair himself — is this: The fat are always less likely to be fit than are the lean. The absolute numbers bear this out. Of Blair's total universe of people, 8100 of the lean were fit, 6000 of the overweight were fit, and only 3307 of the obese were fit. But that did not make the editorial — or cultural — cut either. Neither did the fact that those 3307 almost certainly had to work a lot harder to get that fitness. They could likely do that only because they were, as a group, much richer than most Americans. Remember, Blair's real message, almost always lost on its readers, is largely one of class: Yes, you can be fit and fat if you are rich, white, and male. As, again, were all members of the Cooper population.

It would take a hard heart to say it is wrong to tell fat people that they can become fitter by exercising more. They can become fitter. There is also nothing wrong — and everything right — with preaching a doctrine of self-acceptance to go along with that advice. One should not hate oneself because one is fat. But one should not be led to delusion. Weight matters. It always matters. If one is obese, losing weight is key to obtaining optimal health.

There may, however, be something downright cruel about implying that "anyone" can be fit and fat, especially when the principal examples of that are rich white people who have the time, money, and energy to train — not for ten minutes three times a day — but for marathons. Marathons!

Consider a typical example, inevitably trotted out by Blair for some poor general-interest reporter who needs an example of how one can be fit and fat.

His name is David Alexander. Over the past seventeen years he has finished 276 triathlons in 37 countries. He trains so much that

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he sleeps only four and one half hours a night in order to do so. In a week, Alexander will swim 5 miles, run 30, and cycle 200, and on top of that might compete in not one but two triathlons. Alexander is also, at 5'8" and 260 pounds, "a big boy," he likes to say, "and I'm always going to be big, but I'm healthy." Only much later on in the story do we find out why he is healthy. Alexander is the co-owner of an oil company. There he inhabits an office, we are told, where he sits "surrounded by the antique maps he collects." As is the case of most Americans, for Dave Alexander, fitness is purchased.

But is he really fit? What of the illnesses that derive from fatness that have nothing to do with cardiovascular health? What about type 2 diabetes? On that count the most recent scientific literature is sobering and clear: Alexander is much more likely to get it than he would were he leaner. As a study by Harvard's Departments of Epidemiology and Nutrition and Schools of Public Health concluded in 2001: "The most important risk factor for type 2 diabetes was the body mass index . . . Even a body mass index at the high end of the normal range was associated with a substantially higher risk [than a lower body mass]." How substantial? "More than 61 percent of all cases could be directly attributed to overweight." Although some studies have shown that exercise can somewhat mitigate those risks in fat people, the overwhelming consensus among diabetes experts is perhaps best summed up by a quotation from the director of a New York medical program trying to treat the disease. "Bring me a fat man," this physician told the Times, "and I'll show you a diabetic, or someone who will become one."

Excess abdominal fat cells are troublesome in and of themselves for another reason: They are, metabolically, the laboratory of so-called Syndrome X. The syndrome, first identified by the Stanford endocrinologist Gerald Reaven, acts as the precursor to both type 2 and, eventually, full-blown insulin-dependent diabetes. Excess weight is implicated in its progression. This is because, in at least 30 percent of all Americans, insulin-resistant fat

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cells in the gut produce excess fatty acids, which wreak havoc by attacking the body's vital sugar- and fat-processing functions. The more insulin-resistant fat cells, the more destructive fatty acids. This in turn results in everything from hyperinsulinemia (leading to diabetes) to excess blood fats (leading to artery-clogging) to constricted blood flow (leading to hypertension). Although particularly rampant among the poor and recently modernized peoples of the world (and of those in the United States, as described more fully in chapter 6), the syndrome knows no economic barrier when it comes to fat. Fat cells are its engine, fuel-maker, and distribution network.

As a person ages, excess weight becomes problematic for another reason: bone disease, which it can both cause and complicate. Osteoarthritis of the knee is a case in point. Being heavy drives the progression of this painful disease. A pound of extra body weight places from two to four pounds of extra stress on the knees and hips, even during routine movement, let alone the stress of marathon-like exercise regimes. In the arthritic knee, which takes the majority of the pounding, that stress causes the cartilage to wear away, letting exposed bone surfaces grind against one another. That brings even more swelling, pain, and difficulty in moving about in general.

And that, however the epidemiologists cut it, just ain't fit.

But then, by millennium's end, most Americans were not fit. They were exercising less, eating more — and, thanks to the permissive culture they had created — not feeling very bad about it, thank you very much. It was, after all, a comfortable world, one where a bit of housework sufficed for exercise, where it was okay to gain weight as one aged, where it was healthy to be fat, where the medical consequences of their behavior seemed remote. Even though those consequences were exploding right under their noses.

WHAT FAT IS, WHAT FAT ISN'T

By the MID-1990S the consequences of boundary-less America were everywhere apparent. Physicians in inner-city hospitals were seeing unprecedented numbers of children with type 2 diabetes. (Until then type 2 had been a disease seen almost exclusively in adults.) In the medical literature, obesity was declared a main cause of soaring rates of early puberty among girls as young as nine years old. Fatness also lay behind a disturbing rise in the rate of Pseudotumor cerebri, which, as its name denotes, is a brain tumor-like condition, often found in obese women. Weight-induced sleep apnea, hypertension, and arthritis of the knee were on the rise too.

Yet as the studies trickled in, and as various interest groups parsed their meaning, one fact stuck out above all others, at least to those who were on the front lines of studying and treating the phenomenon: In late-twentieth-century America, it was the poor, the underserved, and the underrepresented who were most at risk from excess fat.

While new studies, particularly those from the CDC, showed that the fat epidemic was slowly but surely crossing over into the middle and upper middle classes, particularly among men, the

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most consistent numbers concerned the poor and the working poor. Among these classes, obesity was rampant. At the very bottom end were households with less than $10,000 of annual income; among them, 33 percent of blacks were obese, 26 percent of Hispanics, and 19 percent of whites. For households with $20,000 to $25,000 in annual income, the rates were substantially lower; 27 percent of blacks, 18 percent of Hispanics, and 20 percent of whites were obese. At the $50,000 and above mark, the rate of blacks who were obese fell to 23 percent, Hispanics rose to 22 percent (perhaps reflecting the prototypical response to new middle-class status), and whites fell to 16 percent.

Culture, ethnicity, gender, and race, of course, also play their roles in determining obesity rates. Black girls and their mothers, for example, tend to be heavier than their white counterparts regardless of income level. Such findings have driven researchers to look deeply for what might be behind such a variable. Was it the long-held (but bogus) notion that blacks are more comfortable being fat? No. Was it, as one scholar proposed, because being fat was a way for a young woman to keep predatory young men at bay? No. The reason, a group of epidemiologists from the University of Pittsburgh concluded, was money. "The relationship of income and obesity [among black girls] . . . appears to be more akin to that of white girls in the 1960s and even to that of traditional societies," they wrote. "What we observe ... may be a reflection of a differential social development in our society, where a certain lag period may need to elapse between an era when food availability is a concern to an era of affluence with no such concern before an inverse relationship between socioeconomic status and obesity [among blacks] can be seen." In other words, blacks still have not caught up to whites economically, and so still think about food as if scarcity were just around the corner.

The point is not that culture or race does not matter. They do. The point is that class almost always comes first in the equation: class confounded by culture, income inhibited by race or gender,

no

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buying power impinged on by ethnicity or immigration status. But why are the numbers of the obese poor suddenly soaring so? One answer is that the same culture that had made possible the huge gains in middle-class obesity is also at work among the poor. Being poor may even magnify the effect. The poor, after all, lead lives that are more episodic than those of the more affluent. They are more likely to experience disruptions in health care, interruptions in income. Food, and the ability to buy it, comes in similar episodes — periods of feeling flush, periods of being on the brink of an empty pantry. The impulse is to eat for today, tomorrow being a tentative proposition at best.

Consider the situation among the poor in the nation's capital. There, obesity has become the defining metropolitan aesthetic. One of D.C.'s most popular clothing stores is Ashley Stewart, a national discount chain specializing in plus-size clothing. Fast food is also ubiquitous — on the street and in the schools. Fast food in the schools, in fact, seems to be a matter of pride. When the D.C. inspector general publicly criticized one school principal for selling fast food on campus, he was immediately shouted down by a number of elected public officials, who defended the principal by saying that he was merely being "enterprising."

The less visible signs of the D.C. obesity epidemic are even more troubling. At Howard University hospital, physicians doing their preliminary patient workups must often use the scale in the downstairs laundry room; it is the only one in the hospital big enough to weigh some of the patients coming in for obesity-related ailments. In the winter of 1999 physicians at the same hospital witnessed something they thought they would never see: a fifteen-year-old girl who died from an enlarged heart. The girl weighed 400 pounds.