Fat land : how Americans became the fattest people in the world (20 page)

FAT LAND

eleven already have it.) With clotted, constricted, and overloaded arteries, the stage is set for all kinds of vascular mischief, one of the most deadly of which is stroke. Stroke happens when all of these conditions cause the vessels of the human brain to become blocked, depriving the organ of much needed oxygen and nutrients and causing it, eventually, to cease functioning.

The brain suffers from obesity in other ways too, responding with a condition known as Pseudotumor cerebri. As the name suggests, this is a brain tumor-like condition caused when excess abdominal weight presses down upon the lungs and the heart, causing increased pressure on the vein returning blood from the brain. The most common symptoms are headaches, vomiting, blurred vision, and double vision. Obesity occurs in 30 to 80 percent of children with pseudotumor. The chances of a child getting the condition increase by twenty times when body weight exceeds 20 percent above the ideal.

Then there are the orthopedic problems. First comes the obvious: arthritic joints caused by simply carrying too much weight. Next is a condition known as slipped capital femoral epiphysis — a slipped hip. Obese children succumb to it much more often, and at substantially younger ages, than the nonobese. Its consequences can be painful and chronic and eventually require surgical insertion of a screw in the hip. The same can be said of Blount's disease, also known as Tibia vara. In Blount's, the legs respond to early weight excess by becoming bowed, and contrary to popular conceptions about bowed legs, this is not merely a cosmetic inconvenience. Consider a recent case report, detailed by J. Richard Bower, the chief of orthopedic surgery at the Alfred I. Du Pont Institute: "The patient is a 14 and one half year old black male with a one year history of worsening left knee pain. He states that the pain began in both knees and was intermittent. . . . Over the past six months the pain is more isolated to the left knee and has become constant in nature. Within the past two weeks the constant pain has become bad enough to limit his activities. He is unable to attend school or walk more than several

WHAT THE EXTRA CALORIES DO TO YOU

hundred feet because of the pain. The pain is now affecting his

sleep The adolescent is morbidly obese." As are 80 percent of

children with Blount's.

Now drones the true dirge of the obese child — respiratory diseases. These come in three forms. The first, Pickwickian syndrome, is named after the ever somnolent Joe the Fat Boy in Dickens's Pickwick Papers. The syndrome starts when large amounts of abdominal fat cause the child to breathe in a rapid, shallow fashion, with increasing intervals of breathlessness. This leads to oxygen deprivation, chronic sleepiness, and, if untreated, heart failure. Excess fat tissue in the throat and uvula is also the direct cause of obstructive sleep apnea in obese children, a third of whom display the main symptoms of apathy, listlessness, nighttime sleeplessness, and daytime somnolence. More troubling are the condition's effects on learning. According to a report in the International Journal of Obesity, "Obese children with obstructive sleep apnea demonstrate clinically significant decrements in learning and memory function."

Lastly there is the condition known as allergic asthma. For the past three decades, epidemiologists have watched a progressive rise in this wheezing condition, particularly among children between five and eighteen. The two principal theories about its origin — increased time spent around or near indoor allergens and the rise in childhood antibiotic use — have recently been joined by a new theory of causation: the general decline in childhood physical activity. In this scenario, lack of the strengthening effects of exercise leads to weakened lungs, making it easier for wheezing reactions to set in. A study by the Respiratory Sciences Center at the University of Arizona showed that females who became overweight or obese between six and eleven years of age were seven times more likely to develop new asthma symptoms than those who were normal weight.

Obesity makes for special problems when fat girls grow up to become fat mothers. Women who are overweight or obese before becoming pregnant are much more likely to develop gestational

FAT LAND

diabetes and hypertension of pregnancy, also known as preeclampsia; they will inevitably need longer and more intensive hospitalization. A mother's excessive pre-pregnancy weight also greatly increases her chances of having a baby that is stillborn or that will die shortly after birth. If the child survives, he or she is 30 to 40 percent more likely to present with a variety of birth defects, ranging from spina bifida to heart malformations to defects in the abdominal wall. Folic acid supplements are less likely to prevent such defects in the offspring of the obese, who are at increased risk of becoming obese themselves, thereby setting in motion the vicious cycle once more.

As if all of this were not enough, the obese child who becomes an obese adult will also have an increased risk of cancer. In early 2001 the American Cancer Society, after years of deliberation, issued a special statement on the connection in its annual Cancer Facts and Figures. Obesity, the society declared, was "linked to an increased risk of breast cancer after menopause and to cancer of the endometrium, ovaries, colon, prostate and gall bladder." Again, much of the problem derives from excess visceral fat cells, which, among other things, play a key role in converting estrogen to estradiol, a more active form of the hormone that can promote tumor growth. If the obese individual is insulin-resistant, compensatory oversecretion of insulin will cause overproduction of insulin-like growth factor, related, in turn, to growth factors that bring about colon, breast, and prostate cancer. Cancer, the obsession of twentieth-century medicine, has entered the new millennium as the special burden of the obese.

As Fran Kaufman had observed, something had indeed changed.

Outside of the medical consequences to the individual, what are the economic consequences to the nation if obesity is merely incorporated into the American way of life rather than resisted?

There are, first and foremost, the premature deaths of more than 280,000 Americans every year, the figure the American

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Medical Association now believes reflects the number of obesity-related mortalities. There is the $100 billion annual price tag for the care and treatment of diabetics, the majority of new cases being a direct result of excess weight. That boils down to one in every ten dollars dedicated to health care. In terms of federal resources, diabetes alone commands one in every four Medicare dollars. These are considered to be conservative estimates. Most policy experts on the subject believe that diabetes is subject to the classic epidemiological "rule of halves"; because of its overwhelming residence at lower social addresses, and because one can have the disease for long periods of time without feeling sick, only half of all diabetics are ever diagnosed. Of those, only half are ever treated. And of those only half ever have their disease managed effectively.

Obesity takes its toll on our daily quality of life too. Between 1988 and 1994 the number of days of lost work due to obesity increased by 50 percent — to 39 million days, worth $3.9 billion. There were also 239 million restricted activity days due to obesity, 89.5 million bed rest days, and 62.6 million physician visits, the last equivalent to an 88 percent rise over 1988. As A. M. Wolfe and G. A. Colditz of the University of Virginia concluded in a study of such costs among a population of 88,000 U.S. residents, "The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States' (emphasis added). As a recent RAND/University of Chicago report noted, "More Americans are obese than smoke, use illegal drugs, or suffer from ailments unrelated to obesity."

How will the average person feel obesity's economic pinch? To figure that out, four researchers from the independent Policy Analysis Inc. (PAI) set up a sophisticated model of a hypothetical HMO with 1 million members. Using reference data from a large managed health care plan in the Pacific Northwest, the researchers then projected the number of cases of eight diseases for which obesity is an established risk factor (coronary heart disease, hypertension, hypercholesterolemia, gall bladder disease, stroke,

FAT LAND

type 2 diabetes, osteoarthritis of the knee, and endometrial cancer). The results were mind-boggling, even to jaded public health types. In a population of I million, the PAI researchers found, "obesity would account for 132,900 cases of hypertension (45 percent of all cases), 58,500 cases of type 2 diabetes (85 percent), 51,000 cases of hypercholesterolemia (18 percent), and 16,500 cases of coronary heart disease (35 percent)." The total costs of obesity to the HMO? $345.9 million annually, or 41 percent of the total for the eight diseases studied — "substantial," as the researchers put it.

And what will happen when people who take care of themselves start to understand why their own health care bill keeps skyrocketing? "We believe the effect will be like that of secondhand smoke," says James O. Hill, of the University of Colorado and the dean of American obesity studies. "When people who are fit really begin to understand this, it will be a catalyst for one of two things, though likely both: anger, and then a demand for change." Hill has been studying the phenomenon in Pueblo, Colorado, where groups of patients, health providers, academics, physicians, and policy makers are trying to come up with a way to involve HMOs more directly in treating and preventing obesity. "The main thing we see is real shock when people digest this. They get very worked up — and why not? They are taking care of themselves. But they also want to know: What can we do besides just throw more money at this?"

One approach would be for HMOs to get more proactively involved in identifying obesity-related problems within their contracted populations. An enlightened HMO might sponsor a free blood sugar testing clinic, with employees who test high being counseled to schedule more complete workups in the future. But what then? Not a few fat people's rights organizations would argue that such an approach would merely legitimize discrimination against the obese, giving them a medical stigma to go with their aesthetic stigma. (Yes, this may sound crazy, but such concerns are a fact of life in large organizations, particularly large

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governmental organizations, where obesity rates run particularly high.) Moreover, mainstream (read: middle) America remains in deep denial about obesity; it will likely be some time until the culture connects the proverbial dots and demands such testing. As Gerry Oster, one of the authors of the PAI study, says, "We have a long long way to go until the average person gets a clue about the connection. I am not representative at all of the typical attitude toward obesity. None of my friends are obese; we are coastal professionals involved in health care research. But go to the Mall of America in Minneapolis — I'd bet the obesity rate you see there is 75 percent or more." A culture that condones obesity, whether consciously or unconsciously, undermines any attempts to convince people to pare down.

Yet not taking such basic preventive measures merely encourages more rampant obesity, which, in turn, fuels its own kind of social sorting, one based on both aesthetics and social class. The aspiring classes of the country tilt toward thinness as a social goal. Perusing the pages of any "New Economy" magazine of the 1990s, one was pressed to find a single example of an obese CEO, let alone an obese venture capitalist. Ditto today's heroes in Fortune or Forbes. The operative notion is simple: If one can't control one's own contours, how can one be trusted to control someone else's money?

Even the Clinton-Lewinsky scandal had a strong taint of upper-class anti-fatism to it. As Jane Gallop, a distinguished professor of English at the University of Wisconsin at Milwaukee, commented in the New York Times, "There's a moment in the Barbara Walters interview where Monica relates that he [Clinton] would always leave his shirt untucked because of his belly, and you just feel that was one of the ways where Monica and Bill get connected. If the right wing in this country is still really moralistic about sex, the left is moralistic about food — that's where the new style of moralism about control is. Well-educated people are supposed to be in control of the amount of body fat they have.

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The people who are disgusted by Clinton's fat and by Monica's aren't the right wing, they're the ones who wanted a yuppie president with the right amount of body fat at the helm."

Although one might quibble with her left-right dialectics (after all, it is George W. Bush who has the right body fat, not to mention a pulse lower than that of Seabiscuit), Gallop clearly is on to one thing: When it comes to fat, the affluent are afraid. Very afraid. They will do anything not to be affiliated with it. In the upper classes, fat is seen as the great cheat — a barrier to performance, a denier of rewards delayed, a mark of the uncontrolled, primal fellow supposedly left behind in the individual's arduous upward economic march. To be affiliated with being fat would put the affluent person on the wrong side of the stigma, where the dynamic would seem to cut the other way — fat attracting fat.

Fat attracting fat! Johannes Hebebrand, the German psychiatrist who was so taken aback by how unashamed obese Americans seem to be, has been studying that side of the stigma for more than a decade. "We got very interested in this area some time ago, when we saw that negative impressions about fat people — as indicated in various surveys and attitude tests — showed a huge jump in just ten years. It led us to ask: If people feel stigmatized, will they be more likely to mate with other stigmatized people, in this case other fat people?" he says. "The other factor was the huge jump in the obesity rate itself, and the fact that everyone was saying it had to be entirely an environmental issue, because twenty years was too short of a time for genetic mutations to appear. We started to think that maybe that was not entirely true. Maybe environment — via assortative mating — was accelerating genetic expression of obesity."