Fatter than Ever

Richard Klein.
Eat Fat. First Vintage Books.
247 pages. $13.00

Robert Pool.
Fat: Fighting the Obesity Epidemic. Oxford University Press.
292 pages. $27.50

Although many Americans are dissatisfied with their weight, personal struggles with body size have not yet generated much political debate. Until now, each individual has battled the problem alone, or at most with the assistance of a doctor or commercial weight loss program. Increasingly, however, we hear voices raised, like that of Robert Pool, to insist that overweight and obesity are a “public health issue” that needs to be addressed by public policy. At the same time, we hear other voices, like that of Richard Klein, perhaps less attended to, but of equal vehemence, insisting that the health consequences of excess weight have been greatly exaggerated by a “fat phobic” culture. Who is right?

We should begin by acknowledging that Americans spend a small fortune every year on diet books, diet aids, exercise equipment, personal trainers, and so-called diet foods. Yet somehow all this expenditure has not reduced their waistlines. Every year, Americans as a group become on average more overweight than before. Time recently reported that more than 60 percent of us are either obese or overweight, whereas 20 years ago, only 47 percent could be categorized as such.

“Obesity” is a medical term to describe persons with a body mass index (BMI)¹ greater than 30; anyone with a BMI between 25 and 30 is deemed merely overweight. According to some estimates, roughly 30 percent of the adult population in America is obese, and obesity is also more common among young people today than in the past. Some endocrinologists believe they now see more cases of early onset of puberty in young girls (some as young as seven and eight) quite possibly caused by excess juvenile weight.

If obesity is a disease, it is a “disease of affluence,” and naturally, America leads the world in obesity. But it is by no means exclusively an American problem; in a recent report, Britain’s National Audit Office estimated that nearly two-thirds of men and more than half of women in Britain are either overweight or obese. International health researchers also report increases in other parts of the world, including not just Europe, but Asia and Latin America.

If you are a casual reader of newspaper health news and advice columns, which tend to equate health with leanness, you may find these trends alarming. In fact, however, the exact health consequences of overweight and obesity are controversial. Most doctors believe that excess pounds increase the risk of early death from heart disease, stroke, and diabetes; and some researchers argue that even a small deviation from leanness is unhealthy. Other health experts, however, are convinced that the relationship between weight and health is quite complex, and that the diet and sedentary lifestyle of many overweight people are more significant risk factors for disease than the poundage as such. In fact, there may be an emerging consensus that most people, even while remaining overweight, can improve their health measurably merely by eating more fiber-rich foods and incorporating more activity and weight-bearing exercise into their daily routines. What is especially important, and acknowledged by Pool himself, is that no one has yet demonstrated that losing weight will make people live longer.

But even if Americans could be reassured that extra pounds need not threaten their lives, it is unlikely that the cultural preoccupation with thinness will soon disappear. A slender physique is desirable in our society, since it is perceived as a marker for both youth and wealth. And it has been that way, say the cultural historians, since the early twentieth century.

In recent decades, however, the high valuation placed on thinness, and a corresponding stigmatization of the overweight, seems to have grown more extreme. The average weight, but not the height, of contestants at the Miss America pageant has been dropping since the 1940s. In 1954, the average weight of the contestants was 121 pounds with an average height of 5 feet 6 inches. By the early 1980s, however, the average weight for a 5’8” contestant was 117 pounds, and the average for a 5’5” contestant was 108.5 pounds. But we shouldn’t single out the pageant for disseminating a starved ideal of female beauty; the same skeletal norm prevails today throughout the entertainment industry. Where now are the movie star equivalents of the full-figured sex goddesses of the past, such as Mae West, Jean Harlow, Ava Gardner, or Marilyn Monroe? Given the surrounding culture, and the stigma against fat, it is no surprise that many young women have become intensely preoccupied with their weight, and that eating disorders, including anorexia and bulimia, have become more prevalent.

Overweight people are frequently viewed as lacking in self-control, and perhaps other desirable attributes, such as competence and intelligence. Consider, for example, the public image of America’s most famous fat person, the television character Homer Simpson, who is irresistibly drawn to food. And it isn’t just him. In a recent court case in New Jersey (one of the few states that includes obesity under its antidiscrimination law), a judge ruled that a fired obese man could sue, provided that he presented medical evidence that his obesity was not simply the product of “overindulgence and lassitude.” At the very time that norms of civility have become more strict, requiring, for example, that we refrain from ridiculing each other for skin color, mental and physical disabilities, or sexual orientation, jokes at the expense of fat Americans still seem socially quite acceptable. Klein complains that “We are still allowed, in polite society, to hate fatties, because fat, it seems self-evident, is hateful.”

Given the intensity of social disapproval of the overweight, why are Americans fat and getting fatter? Despite many plausible theories, no one has yet advanced a completely satisfying explanation, and that is in itself unsettling. Robert Pool argues that overweight is a natural response to an unnatural environment, where calorie-rich food is readily available with little or no physical effort. To illustrate his argument, Pool cites the case of the Pima Indians, a hardy, lean people well-adapted to their rigorous desert environment in the nineteenth century, but today one of the most obese and unhealthy subpopulations in the United States.

Pool is no doubt correct that our modern civilization, in which applied science has furnished us with what our ancestors could only wish for, easily obtainable and abundant food, is the enabling factor for overweight. But Pool’s book does not well account for the timing of the American obesity epidemic: It is not obvious that food was more abundant, or labor-saving devices such as elevators more prevalent, in the 1990s than they were a decade or more back. This is a troubling omission in a book which proclaims that our obesity epidemic “is not an individual problem. It is a disease caused by a sick environment to which some of us are more susceptible than others.”

One possible culprit that Pool mentions, but does not analyze in depth, is the growing tendency of many Americans to rely on the fast food industry for meals. In a recently published, much praised book, Fast Food Nation, Eric Schlosser lays the blame squarely on McDonald’s, Burger King, Kentucky Fried Chicken, et al. “As people consume more meals outside the home,” he writes, “they consume more calories, less fiber, and more fat.” Yet Schlosser does not analyze why Americans, when they leave home, do not seek out purveyors of wholesome food. Why can’t I stop off the highway and find an establishment that offers grilled chicken, a fresh romaine and raddichio salad, and some nice blackberries for dessert? One reason might be that healthy “fast food” would require the use of fresh, in-season ingredients that are costly and resist the standardized preparation that has allowed for labor-saving, low-priced mass feeding. You get what you pay for. But even this consideration cannot explain why in the late 1950s the typical size of a soda order was eight ounces, while the child-size Coke at McDonald’s today is twelve ounces. Yet Schlosser does not hesitate to compare American eating establishments to disease-carrying populations of mosquitoes or deer-ticks: “The obesity epidemic that began in the United States during the late 1970s is now spreading to the rest of the world, with fast food as one of its vectors.”

Richard Klein has his own interesting ideas about why Americans have become so fat. For one thing, he points out, Americans lack what the French call the “discipline of eating,” in which meals are highly structured, ritual social events. The problem with American eating, from this standpoint, is not the fat content of the food consumed, but the atrocious haste with which the victuals are chowed down, so that people do not even give their bodies a chance to regulate intake through the natural feedback process of satiety signals. By contrast, the French sit around and talk, the argument goes, thus requiring them to take time to chew in a civilized manner and thereby to truly savor a well-prepared meal. This is an appealing theory, though as yet the hard evidence is lacking. Americans do seem to have lost the tradition of formal family dining; 61 percent of readers of Bon Appetit claimed recently that they sat down for a family meal at least two or more times a week, but that is hardly a reassuring statistic. On the other hand, maybe France is not such a stronghold of the slender anyway. A recent study of international obesity rates indeed found that the Haute-Garonne region of France had one of the lowest prevalences of obesity; however, one of the regions with the highest prevalence was also in France (Bas-Rhein). Perhaps the next big breakthrough in obesity research will come when we send in a team of anthropologists to compare the rates at which different groups of Frenchmen chew.

Klein also offers another provocative explanation for the American tendency to gain weight against our conscious wills. In his view, precisely because we strive for an unnatural degree of thinness, our bodies are fighting back. Dieting tells the hypothalamus that we are starving; in response, the body lowers metabolism, hoards calories, and desperately sends out hunger signals to the brain. The result is a “yo-yo” pattern of weight loss and subsequent weight regain, which leaves the body ever more reluctant to part with fat reserves.

Klein’s argument that dieting causes weight gain is parsimonious and nicely paradoxical, and it fits some facts. Unfortunately, it is also at odds with at least some other important ones. For example, studies show that American black women tend to be satisfied with their bodies and yet are significantly more overweight than white women. Nor is it likely that the “rebound” effect of rigorous dieting has much to do with excessive weight among males, since they are less likely to engage in dieting.² In fact, the true causal relationship may run in exactly the opposite direction from what Klein posits: Instead of becoming fat because we try too hard to be thin, it may be that we overesteem thin because we ourselves are fat.

But obesity research supports Klein’s contention that the human metabolism defends a certain “set-point,” a particular weight at which the body feels comfortable. In one famous experiment, state prison inmates volunteered to stuff themselves until they had increased their body weight by 25 percent. The prisoners almost uniformly found the process difficult and unpleasant. And interestingly, only a few, when allowed to eat normally, had any difficulty shedding the pounds and returning to their normal weight! We all readily accept that the human body tries to maintain a steady level of physiological variables such as temperature or amount of sugar in the blood. Yet many of us resist the idea, strongly suggested by this experiment, that some powerful homeostatic principle may regulate each individual’s fat stores and body weight.

Unfortunately, for most of us it seems that homeostasis is very much in evidence when we are trying to slim down, but almost unnoticeable when we really need it, for example, in the weeks after Thanksgiving. Apparently, the set-point in most people tends to drift upwards with age. Moreover, in some people the set-point seems always poised to head upward with only the slightest provocation, such as a decrease in physical activity as when the Pima Indians no longer had to engage in back-breaking agriculture or to run all day to defend agains Apaches.

Pool’s book is especially valuable in documenting the scientific research which helps explain why the efforts of those who earnestly seek to reduce weight meet with so little success. In his view, Americans spend money on the products of the weight-loss industry because they accept outdated conventional wisdom about the relationship between diet and weight. The conventional wisdom — still propounded in numerous “fitness” magazines and taught in high school health classes — is very simple: When people consume more calories than they use, the body stores the excess as fat. So losing weight is relatively straightforward as a matter of physics; you just eat less and exercise more.

Unfortunately, the matter is by no means so simple, once we introduce the perspective of biological self-regulation, because “hunger,” the urge to eat, seldom smoothly adjusts to the new body weight achieved. In fact, it appears that at least for those who are 20 or more pounds overweight, appetite only infrequently adjusts downward as it “should.” But we Americans are an optimistic people. Hardly anyone investigates the long-term success rate of a commercial weight-loss program before signing up.

Some will view skeptically the argument of medical researchers that obesity is best understood as a disease, a disorder of appetite, not a failure of self-discipline and moral character. Conservatives especially are inclined to resist the “medicalization” of behaviors that were once perceived as clearly moral failings (for example, alcoholism, homosexuality, kleptomania, etc.).

But if there is any area where a biologically based understanding of human behavior is justified, surely the drive for food must be it. If our ancestors had not been powerfully motivated to search for food, they would have stayed all day in their caves engaged in occupations, such as exchanging gossip, or discussing art and philosophy, of intrinsically greater interest than food collection. All of us know people who are able to maintain a normal weight without struggling. In fact, many of us can remember in our younger years having been such people ourselves. Consequently, although decisions about what and when to eat appear to be individual, discrete, and seemingly under our conscious control, obesity researchers deserve a respectful hearing when they discount the “illusion of free will” in relation to daily food intake. Accepting that different individuals may, because of genetic endowment and age, have naturally different appetites and body sizes does not necessarily mean endorsing a mechanistic, reductive view of human nature as a whole.

But not all the evidence supports the view of overweight and obesity as a fact of nature outside of rational human control. For one thing, in America, obesity and overweight are negatively correlated with income and education. The wealthier you are, the more likely you are to be slim. It is possible, of course, that wealthy people have a genetic endowment that predisposes them to thinness; but it is hard to believe that God is that unfair.

But if not genes, what could explain why, in America today, the rich are thinner on average than the poor? Part of the explanation is almost certainly the same as the reason that fewer upper-income people today smoke cigarettes; their subculture influences them to cultivate health-conscious habits. In addition, it is probably the case that remaining slender is facilitated, not only by personal discipline, but by the investment of time and money. In the good old days, people from most social classes tended to walk to places where they wished to go. Nowadays they drive, and if they want exercise, they need to join a health club, or buy home equipment (and find a place to store it). And it is not just a matter of money, but also time. Just to cite one example, both time and money are needed to make low-calorie meals as sensually appealing as the kind we may have grown accustomed to eating. Rush Limbaugh should be congratulated on his candor for explaining that his breakthrough in weight reduction came, not only after he stopped drinking, but when he could free himself from the burden of counting calories and obsessing over food choices by the simple expedient of hiring a first-rate chef!

It would be interesting to know whether the actual content of the daily calories consumed has a stimulating (or conversely a dampening) impact on appetite. Studies of mice show that some diets are indeed more “fattening” than others. Despite the undeniable difference between laboratory mice and ourselves, we are not terribly surprised to learn that in one experiment, mice fattened up on a diet high in fat and sugar, but others got skinny on a cuisine adulterated with bitter-tasting quinine. The implications of this experiment would seem to be that a rich, delicious diet is fattening, and that you eat more when the food tastes good. This can be easily verified from experience, as when one is tempted, after a perfectly adequate meal, to squeeze in a slice of chocolate mousse-cake. A similar principle underlies the fad diets that were quite popular in the 1940s and ’50s, the kind that advised eating only grapefruit and toast, or only Jell-O. These diets “worked” because people got bored with only one food, and so lost some of their appetite, and so lost weight at least in the short run (though with very negative consequences for their overall nutrition and health). A similar principle is behind the advice frequently given that dieters should not keep “tempting” foods, such as brownies, potato chips, etc. in their homes. No one, the theory is, even if feeling hungry, will binge on lettuce or celery, or even mangoes and raspberries.

The idea that people seek a certain amount of sensual gratification from their food each day, and will consume fewer calories so long as they are not deprived of it, is behind all the efforts to develop substances, such as Nutrasweet and Olestra, which attempt to comfort us without the calories. But if the obesity research on homeostasis is correct, these efforts to deceive the taste buds will not have much impact on the underlying problem, which lies not in the palate, but in the hypothalamus, which is not so easily fooled. As Richard Klein has noted, when people see that a food is labeled “low-calorie,” they frequently take that as a license to eat more. And the real mechanism may not even be conscious.

The alert reader will have noticed that, in the above discussion, we have encountered two quite different philosophies of weight control. According to one, we should eat only controlled portions of stuff we really like (in my case a chocolate-dipped anise biscotti with coffee at mid-morning) so as to feel psychologically gratified. This takes some discipline. According to the second viewpoint, we should only eat food that does not especially appeal to us, so we won’t be tempted to eat too much. This takes even more discipline. There can’t be much future in a diet plan that allows people to eat as much as they want of food they hate. But perhaps the two positions can be synthesized, if the real trick is to habituate ourselves — gradually — to good-tasting low-calorie meals.

Unfortunately, the scientific understanding that food intake is regulated by a complex set of molecular signals does not mean that doctors understand these mechanisms well enough to manipulate them to our advantage. Nevertheless, we keep trying, and huge sums are invested each year in the search for appetite-suppressing pharmaceuticals. Because so many Americans are already either obese, overweight, or afraid of becoming so, the potential profits in a successful weight-loss drug could be enormous. But the history of such drugs so far is a record of failure. There was dinitrophenol in the 1930s, which raised the body’s metabolic rate and definitely caused weight-loss, but with frightening side effects, such as headaches, weakness, vomiting, and diarrhea, to say nothing of fever-induced death. Then came the amphetamines, which suppressed appetite successfully, but whose side-effects, such as heart problems, addiction, and (in large doses) paranoia were not at first recognized. There was a flurry of excitement with the discovery of leptin in 1994, but this substance, naturally occurring in the body and believed to signal satiety to the brain, was not the magic bullet either (except for a few people with rare genetic disorders). The most recent supposed miracle drug was fen-phen, which was so popular in the 1990s, before its deadliness was discovered, that pharmacists had great difficulty keeping it in stock.

Both pool and Klein are opposed to weight-loss pharmaceuticals, and given the record of truly alarming side-effects thus far, they are well within their rights to be suspicious. But the alternatives to medication are only two: (1) accept a certain level of overweight as natural to the particular society we live in, or (2) attempt to engineer society so as to remove the temptation to overeat and exercise too little that contributes to obesity. Klein recommends the first; Pool the second.

There would be no need to medicate ourselves if we simply accepted our overweight condition. Thanks to the iconoclastic work of Richard Klein and others, we are able to consider what a defense of fatness might look like. Klein reminds us that our current lean ideal is unrepresentative of the way human beauty has been perceived historically, and his case here is solid enough. Unfortunately, standards of physical beauty in our species, although culturally variable, do not seem highly amenable to rational control. In the past, people living with precarious food supplies saw a fleshy human form as signifying health and prosperity. Even today, in Niger and many other parts of Africa, the ample body is admired, and modern-minded women even take steroids to help themselves bulk up. But in the absence of a global threat to the world food supply (which Klein wistfully entertains) or a definitive pharmaceutical solution (“When everyone can be thin by popping a pill, suddenly fat will look hot”) it is difficult to see how we can rid ourselves of the beauty ideal appropriate to our own level of food abundance.

Pool argues that even if weight-loss drugs could be perfected, long-term medication is the wrong approach, and that we should instead devise social policies aimed at altering the environment that is “making people sick.” His recommendation would be more meaningful if we had something other than the vaguest idea as to which factors are really responsible. Should your remote channel changer be treated as a disease pathogen? Your car? What exactly does Pool want to do — program your television to spy on you and shut off if you eat while you watch?

One is tempted to dismiss Pool’s plea for new social policies as merely rhetorical. But on reflection, there are possibilities. Taxing “low-nutrition” food and banning commercials for fatty snacks were proposed, in perfect seriousness, some years ago by Kelly Brownell of Yale University. Some European countries have banned television advertising aimed at children, which has the salutary effect of making it more difficult for tots to find out about Happy Meals. One can easily imagine even more aggressive policies, such as tax credits for health club memberships and home gym equipment. Perhaps we could install electronic monitors on cardio- machines to report the intensity and duration of our workouts to the IRS. Come to think of it, why fool around with the resource input side of public policy? We could get direct and just tax poundage, adjusting for height.

Pool maintains that food abundance and lack of daily opportunities to exercise are analogous to toxic smog. We would be wrong, he argues, to focus on treating individuals who are most sensitive to smog; it is our responsibility to eliminate the environmental conditions that made them sick to begin with. Another example Pool uses is the dosing of little boys with Ritalin to make them conform to an unnatural school setting. But a better analogy might be our public policy response to a substance such as alcohol, which, like food, can be consumed and enjoyed in moderation by most people, but which has extremely negative consequences for those people susceptible to overindulgence. If the analogy to alcohol is the best one, the implication is that a war on fat would be waged, like the “noble experiment” of Prohibition, at great cost to our liberties and with little prospect of success.

If we are to have a free society, there must be some limit to how far government can go in compelling citizens to do things “for their own good.” John Locke in the “Letter on Toleration” deemed it obvious that “in the conservation of bodily health, every man may consider what suits his own conveniency, and follow what course he likes best.” For Locke, the person who ruins his own health through excessive intake of food or drink was the example to clinch his case against unjust political intrusion into private decisions in other matters, such as religion. If government must address the obesity epidemic at all, the legal acceptance of drug therapy — provided that it is voluntarily undertaken by informed patients — is surely preferable to Big Brother.

The obesity epidemic in America is real, though it is far from clear that the problem can be helpfully addressed through government policies. We could remove soda and candy machines from public schools and schedule gym class for every day of the week, but no one should overestimate the likely impact of these or similar measures. Klein and Pool do a good job summarizing the state of our current knowledge regarding overweight and obesity, and from this summary, it is clear that we still know far too little for government to venture forth with confidence to reform anyone’s eating habits. The problem goes beyond the issue of obviously fraudulent weight-loss programs, such as those that promise “effortless,” “miraculous,” and “magical” results. Even the research findings of respectable institutions using “scientific” methods have produced a mass of contradictory findings and advice. Americans are rightly tired of “expert” medical opinion that changes from year to year, and even month to month. First butter is bad and margarine is good, but then it is learned that margarine is worse than butter, and neither is as good as olive oil. First fat is bad, but then we learn that too much sugar is bad, and then too much protein is bad, so does that mean that food is bad, period?

One unequivocal scientific finding, however, deserves greater public dissemination, even though it goes against the grain of our optimistic, relentlessly self-improving American culture (and the weight loss industry which caters to it). The old adage that an ounce of prevention is worth a pound of cure is particularly relevant to weight, and honest health education needs to help people understand the biological mechanisms that make weight gain so difficult to reverse. The great twelfth century philosopher and physician Maimonides advised his patients that it was best to leave the dinner table while still retaining some appetite, and before reaching the point of full satiety. Maybe he knew what he was talking about.