From Radiance Winter 1998
From Chapter 6:
Is Obesity a Killer Disease?
Is obesity really a disease? Do people get sick and die because of the extra pounds they carry on their frames? Is it, as the Oxford English Dictionary defines disease, "a condition of the body . . . in which its functions are disturbed or deranged"? Are fat people always unhealthy?
Two prominent obesity researchers who recently formed the American Obesity Association (AOA), University of Wisconsin physician Richard Atkinson and University of California at Davis nutrition expert Judith Stern, say obesity is a disease, and many of their colleagues share their view. "Obesity is a disease that affects at least 70 million Americans: more than one-third of all adults and one in five children," the researchers state in their AOA brochure. "Some people are more susceptible to obesity than others. Each year obesity causes at least 300,000 excess deaths in the U.S. and costs the country more than $100 billion. Obesity is the second leading cause of unnecessary deaths." The researchers describe obesity as responsible for increasing the risks of high blood pressure, diabetes, heart disease, stroke, gallbladder disease, and cancer of the breast, prostate, and colon. These very same statistics and lists show up frequently in the literature on obesity, as well as in books promoting diets, at FDA hearings on new diet drugs, in patient brochures in diet doctors' clinics, in medical weight-loss product sales packets sent to physicians, and in ads for commercial weight-loss centers. The campaign report for "Shape Up America," the C. Everett Koop Foundation's 1994 health crusade, for instance, uses these numbers, and calls obesity "one of the most pervasive health risks affecting Americans today.
. . . There are, in fact, a number of questions about obesity and health that researchers are quite divided on: Does obesity lead to illness, and if so, how? How fat do you have to be to be at risk? Is being fat dangerous, or is it the sedentary lifestyle that often goes along with being fat? If you lose weight, will you be as healthy as a person who was never fat to begin with? There are no clear answers to these questions, and given the confusion, it pays to be skeptical when some obesity researchers call fatness a "disease" or fire off statistics about how many people it kills.
. . . The next claim worth examining is that obesity causes 300,000 excess deaths per year in the United States. This claim is based on an estimate, done by researchers Anne Wolf and Graham Colditz at Harvard Medical School, using data from the Nurses' Health Study (the same study from which the Harvard researcher JoAnn Manson claimed that being 10 or 20 pounds overweight led to an increased risk of early death). Based on the number of women who died from various diseases, and their body weight, the researchers extrapolated that obesity was the direct cause, nationwide, of 171,490 coronary heart disease deaths, 39,679 diabetes deaths, 53,087 cancer deaths, and 10,000 cerebrovascular deaths per year.
But the problem with this kind of analysis, say other researchers, is that you can't make a direct cause-and-effect link between obesity and diseases. Just because people who are fat are more likely to die of cancer doesn't mean that their fatness caused the cancer. Other lifestyle factors that tend to go along with obesity, which the researchers in the Nurses' Health Study did not take into account-such as a lack of exercise or a high-fat diet-may have contributed to the deaths, not the fatness itself.
Studies on obese people who exercise, for instance-who live longer than lean people who don't exercise-may prove that inactivity is the cause of many of the problems we associate with obesity, not obesity itself. Steven Blair, an exercise physiologist at the Cooper Institute for Aerobics Research in Dallas, has done studies that show that if you exercise, your weight (up to a BMI of 40) doesn't put you at any increased risk for early death at all. It may turn out that obesity is, for the most part, a red herring in the health debate.
"Nobody ever dies of obesity," says David Levitsky, a nutrition and obesity expert at Cornell University. Obesity, he says, is often a marker for other health problems caused by a sedentary lifestyle, but is itself not necessarily dangerous. "If you're a large person and you do not suffer from any other health problems, then there is no reason for you to lose weight.
If a person does suffer from other health problems, however, then serious obesity may indeed aggravate the situation. Almost all of the studies that look at the health risks associated with obesity- ...high blood pressure, high cholesterol... or blood sugars, diabetes, or other conditions that often go along with being fat-show that those risks do increase when people are very fat, meaning about 100 pounds or so overweight. In particular, researchers have shown that having abdominal obesity-an apple shape-can be dangerous.
Belly fat is rather active in the body, unlike fat in the hips and thighs, which sits there and causes no harm. Fat cells in the abdomen release fatty acids into the portal vein, which goes directly into the liver, where they interfere with the liver's job of breaking down insulin, thereby increasing the amount of insulin circulating in the body. This sets off a vicious cycle known as insulin resistance: with more insulin circulating, cells grow more resistant to what it does-regulate the metabolism of sugars, protein, and fat-and so produce even more liver-damaging fatty acids. Eventually, this can cause problems, including high blood sugars, high blood pressure, high triglycerides, lower HDL (good) cholesterol, and heart attacks. Regardless of BMI, many researchers say that having a waist-to-hip ratio (waist measurement divided by hip measurement) of less than 0.80 for women or 0.95 for men is likely to be healthy. So men with beer bellies are much more likely to have health problems related to their weight than women with big hips and thighs.
The bottom line isn't that obesity causes 300,000 deaths per year. It's more accurate to say that an unhealthy lifestyle contributes to those deaths, and that obesity sometimes goes along with an unhealthy lifestyle. Certainly there are people who never exercise, eat junk food, have high stress levels, and die of heart disease, who aren't a single pound overweight. Severe obesity does seem to make other health problems worse, but that's a far cry from the blanket statement that obesity is a killer disease. Extreme apple-shaped obesity is a special case (it's mainly men who have this condition), because researchers can show directly how belly fat leads to disease. But even belly fat isn't an argument for dieting; almost anyone, says Steve Blair, can fight off insulin resistance with regular exercise.
The claim that obesity is the number-two killer in America (after smoking) doesn't add up in other ways. If being fat is responsible for directly causing so many diseases that lead to early death, then it would follow that as Americans get fatter, more people would be dying from those diseases. But we're not; the Institute of Medicine report notes that while obesity is increasing in the United States, the rates of hypertension, high cholesterol, high blood cholesterol, and cardiac disease-all supposedly associated with obesity-are declining... In other words, we're getting fatter, but we're suffering from fewer of the diseases traditionally associated with obesity. Clearly, the relationship between obesity and life-threatening health conditions is not as simple and direct as many people make it seem.
The statistic on obesity costing the country $100 billion a year is similarly suspect. That estimate was also derived, in part, from the Nurses' Health Study, and the same criticism-assuming that obesity directly causes disease-applies. The $100 billion figure also includes the estimated $33 billion Americans spend per year on dieting as a "cost," which is ridiculous; that money isn't a drain on national resources, but a spur to one particularly healthy sector of the economy-the diet industry.
The health risks of being underweight haven't been calculated into any of these equations... In a 1996 study, David Levitsky and his colleagues at Cornell University analyzed 60 previous studies involving weight and early deaths, involving 357,000 men and 249,000 women (many times more than the Nurses' Health Study), and found that the health risks of moderate obesity were exaggerated, whereas the risks of being underweight have been neglected. For women, there was little relationship between weight and early death at all. For men, after controlling for confounding factors such as smoking and disease, the data showed . . . those men who were very underweight were as likely to die early as people who were seriously obese. For everyone between the extremes, weight wasn't a substantial factor in their death. "The health risks of being moderately underweight are comparable to that of being quite overweight and look more serious than most people realize," Levitsky said.
Another problem with calling obesity a "disease" is that it suggests that everyone who is fat must be suffering from the same disorder, with the same consequences for their health. In fact, people are fat for different reasons and should be treated accordingly. Some people who are fat, for instance, overeat; others don't. For some, being fat goes along with a constellation of other health problems; others are perfectly healthy. A measurement of body weight to height alone (BMT) is really too crude to make any conclusions about a person's health status. Still, most physicians . . . have us step up on the scale first thing.
Physicians warn us to lose weight, in part, because they hate fat just like the rest of us. Obesity, to them, is a disease in another sense of the word: "Absence of ease; uneasiness, discomfort; inconvenience, annoyance," as the Oxford English Dictionary puts it. Physicians, like many other people, feel uneasy in the presence of someone extremely large, and when they have troubles treating the patient, they feel inconvenienced and annoyed...
Doctors not only share our prejudice against fat, they have the added frustration of not being able to help their patients lose weight... Rather than face the Idea that the treatments may be ineffective, they blame their patients for being uncooperative, reinforcing their belief that fat people tend to be weak-willed.
But it's the diet treatments that fail...There is no standard way to treat obesity, as there are widely accepted ways to treat ulcers, diabetes, or appendicitis. Visit ten doctors and they'll give you ten different opinions about how much you should weigh and what you should do to get down there... Most honest researchers acknowledge that they are years away from really knowing what they're doing. "All current methods [for reducing weight], from thigh creams to stomach staples, are like gropes in the dark, and as such, are either totally ineffectual or are no more than counterforces to an incompletely understood regulatory disorder," says Jules Hirsch, a prominent Rockefeller University obesity expert. "There are no cures at this time.".
The Idea that obesity is a disease, however, has given physicians license to keep trying unproven, unnecessary, and often dangerous treatments... "To call obesity a disease," says the University of Cincinnati eating disorders expert Susan Wooley, "tends to suggest that we should keep all our treatments going even if the success rates are low and carry other risks.
. . . The balance of medical risks to benefits has become terribly skewed in obesity treatment. Being somewhat overweight is not a serious health problem, and obesity is not a terminal illness. And even if there are considerable health risks to severe obesity, there is no evidence that medical weight-loss treatments lessen those risks and improve patients' health in the long run. There are, however, good indications that those treatments can lead to depression, eating disorders, physically stressful yo-yo dieting, and, with some treatments, serious side effects and even death. In no other field of medicine are patients routinely counseled to undergo a treatment that has a less than 10 percent success rate, except in oncology, where risky, last-ditch efforts are tolerated because in many cases the patients would otherwise die. "By ordinary standards of scientific discrimination, dieting might well qualify at best as experimental treatment, not valid therapy," says Andrew Lustig, a medical ethicist at Baylor University. In experimental treatment, there are different rules: patients are informed that there's a high probability the treatment won't help them. But with diets, he says, patients are often not informed that the chances of losing weight are low, and that they may be harmed in the process. It's also profitable for physicians to keep on treating obesity as a disease. When people hear that obesity is a disease, it scares them into marching straight to their doctor's office. Inevitably, the more people believe that obesity is a disease, the more they will accept that dramatic medical treatments for the condition-very-low-calorie diets, surgery, and pills-are better for them than the healthier home remedies of exercising regularly and eating more vegetables.
Many physicians, especially those who specialize in weight loss, encourage and sometimes advertise this Idea that obesity is a medical condition that should only be handled by doctors. Their patients see them when they feel they've finally gotten serious about dieting (as if they were never serious when they plunked down hundreds of dollars at Jenny Craig). They believe that their physician will, at last, prescribe the safest diet, the strongest medicine, the most individualized weight-loss treatment, and the latest in "wellness," or "lifestyle maintenance," or whatever else is the current medical marketing phrase.
From Chapter 7:
Thinking Disorders: Obesity Researchers
Like other scientists, obesity researchers are supposed to work by a process of consensus... After they do a study on, say, how much weight people lose after twelve weeks on a combination of a very-low-calorie diet and behavior modification, they submit their findings to a medical journal. The journal sends the paper out to colleagues in the field to review to decide whether the results were . . . significant enough to be published. If the study is controversial, a lively debate over the results usually ensues in the pages of the journals and at medical conferences.
. . . This process, which is designed to be thorough and objective, is supposed to lead to a consensus that represents the closest thing to truth that science has to offer-at least until researchers publish new, conflicting studies that start the whole process in motion again.
But obesity researchers rarely agree with each other. As a result, the advice that physicians and the media offer people based on what these experts say is often confusing. For the most part, the researchers are split into two camps: pro-diet medical researchers and anti-diet eating disorders researchers. A few moderate psychologists and physicians who believe that slow changes in exercise and eating habits will help some people lose weight without starving themselves occupy the center. The medical researchers . . . tend to favor strong interventions, such as very-low-calorie diets, drugs, and surgery. Even though many of them recognize that these treatments are often risky and short-lived, they believe it's better to do something than to allow people to remain fat. The anti-diet researchers, on the other hand . . . often believe that the very treatments physicians recommend are doing their patients more harm than good. They've seen people whose repeated attempts at dieting have led to poor self-esteem and chaotic eating habits. Because researchers who study fat people hold such opposing points of view, there are many conflicting studies out on obesity treatments, and further, those studies get interpreted in very different ways.
. . . Just as dieters feel they have to be thin to have meaningful lives, obesity researchers feel they have to continue to promote diets to have enriching careers. The social pressures they're under to make people thin are very strong. As anorexics and bulimics distort their body size, obesity researchers distort their own data to show that diet failures are really successes... Anorexics look in a mirror and see a fat person looking back. Obesity researchers look at research that shows that diets don't work and come to the conclusion that people should keep on dieting. It isn't fair, perhaps, to suggest that obesity researchers, who work in a culture where their status, reputation, and livelihood depend on how well they promote dieting and diet drugs, are intellectually dishonest. Instead, we should probably say that many obesity researchers suffer from serious "thinking disorders." Obesity researchers' thinking is distorted most by the fact that almost everyone who funds their work is in the diet business. Scientists' careers depend on publishing studies, and they often have to scramble to get the money to do them. In 1995, the National Institute of Health spent about $87 million on obesity research (out of a total budget of $11.3 billion), which funded only a small portion of the studies done that year; the lion's share was funded by companies that are in the business of promoting diet treatments. "The so-called clinical research in this field has been largely paid for by the formula and drug companies," says Wayne Callaway, [M.D.] himself a moderate who opposes most diet treatments in favor of long-term lifestyle changes. Researchers who oppose dieting don't stand much of a chance of getting funding from companies, who know the research will undermine their products.
Diet and pharmaceutical companies influence every step along the way of the scientific process. They pay for the ads that keep obesity journals publishing. They underwrite medical conferences, flying physicians around the country expense-free and paying them large lecture fees to attend. Some obesity researchers have clear conflicts of interest, promoting or investing in products or programs based on their research. Others are paid to be consultants to diet companies, and sit on the scientific advisory boards of Weight Watchers, Jenny Craig, or other commercial programs-while they also sit on the boards of the medical journals that determine which studies get printed. What it comes down to is that most obesity researchers would stand to lose a lot of money if they stopped telling Americans they had to lose a lot of weight. "It's not always out-and-out bias," says Callaway, "but we end up with fuzzy thinking."
The fact that an obesity researcher accepts funding from a diet company doesn't necessarily taint that particular researcher, but there is a stain on the whole field. "It isn't diabolical," says eating disorders expert David Garner. "Some people are very committed to the belief that weight loss is a national health problem. It's just that if their livelihood is based in large part on the diet industry, they can't be impartial." A few of the conflicts of interest in the obesity research field seem quite obvious. Richard Wurtman, the MIT researcher whose company, Interneuron Pharmaceuticals, owns the patent to . . . dexfenfluramine, for instance, was frequently quoted in the media as an expert on the drug prior to its approval . . . without any mention of his financial involvement. Louisiana State University obesity researcher George Bray presented his study on thigh cream without divulging that he'd already licensed the formula for the stuff to three companies.
Some obesity researchers, paid to be consultants to pharmaceutical companies, exaggerate the health risks of obesity in order to testify to the FDA that new diet drugs should be approved. Obesity researchers have been known to promote dieting or drugs in order to sell books-and to increase the numbers of patients flocking to their practices. . . . One eminent obesity researcher, Theodore VanItallie, who is the founder of the Obesity Research Center at St. Luke's Roosevelt Hospital in Manhattan, was also a co-founder, in 1986, of the Englewood, New Jersey-based United Weight Control Corporation, a liquid diet program used in hospitals and outpatient clinics... In 1989, a business journal reported that venture capital companies had invested $3 million in United Weight... VanItallie's participation in the company had something to do with its initial success. "A lot of companies didn't have good medical backgrounds," said Ashok Vaswani, director of Long Island's Winthrop University Hospital's weight-loss program, who told a business reporter why they'd chosen to use United Weight products. "Dr. VanItallie's association with the company put it in good standing." . . . . . . VanItallie defended liquid diets to the media without revealing his own interests. An October 1988 Newsday piece on liquid diets quoted him as saying, "[Liquid] diets are nutritionally easy to control, you get all the vitamins and minerals you need." In that article, he conceded that few people who lose weight on liquid diets keep it off, but he had a ready explanation, placing blame on the dieters, not the treatment. "We tell people that if they're not willing to make a long term commitment to change their way of eating, to learn to keep that weight off, this is not for them." In 1993, VanItallie, now a professor emeritus of medicine at Columbia University College of Physicians and Surgeons, was a member of the National Task Force on the Prevention and Treatment of Obesity, which determined physician guidelines for very-low-calorie diets. The panel also included University of Pennsylvania psychologist Thomas Wadden and Harvard Medical School obesity researcher George Blackburn, both of whom have done several studies funded by Sandoz Nutrition Corporation. Sandoz makes Optifast liquid diets, sponsors medical conferences, has paid for at least sixty published studies on liquid diets . . . Blackburn was also a paid consultant to Sandoz, and Wadden, at one point, worked for Sandoz. The panel concluded, in an article published in the prestigious Journal of the American Medical Association, that very-low-calorie diets are "generally safe when used under proper medical supervision in moderately and severely obese patients." The review didn't contain a whiff of suggestion that the authors each had personal financial ties to the liquid diet company... In light of the research the experts reviewed, their conclusions were rather odd. They noted that the long-term treatment results of very-low-calorie diets were poor; the patients' metabolism dropped, they lost some body protein along with their fat during rapid weight loss, they gained the weight back, and experienced numerous adverse side effects. But their conclusion was that fat people should try them anyway. It doesn't take a scientist to see that the argument for using very-low-calorie diets was not rational; it seemed it was being defended for some other reason.
Despite the biases and conflicts of interest in the field, once in a while obesity researchers take a long view of the terrain and agree on what they see. They may come to a consensus, as they have in the past, that such treatments as jaw wiring, amphetamines, or stomach balloons are harmful, and shouldn't be used. National medical groups write guidelines that oppose the treatments, and physicians who continue to use them may be shunned by their peers, no longer invited to speak at conferences in Hawaii or contribute articles to journals. The last time a strong consensus on obesity treatment was reached was in 1992, when a national task force agreed that diets don't work. That time, however, partly because of the epidemic of thinking disorders that has afflicted obesity researchers, the consensus didn't last. �
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