« Happy New Year (I Hope) | Main | Thank God For Smoking »

January 02, 2007

Supersize This

The New Republic has a fantastic article attacking the obesity myth. Paul Campos, the author, calmly and methodically details the misuse and misinterpretation of epidemiological studies to show that, contrary to what's often reported, being overweight (particularly according to the deeply flawed Body Mass Index) is possibly healthy, and the most important predictor in any case is cardiovascular fitness -- weight is merely a crude stand-in. But mistaking correlation for causation when it comes to fat is but half the story. The hysteria's intensity owes much more to our cultural repulsion towards flab and the massive industry that has arisen to combat it:

Americans think being fat is disgusting. That psychological truth creates an enormous incentive to give our disgust a respectable motivation. In other words, being fat must be terrible for one's health, because if it isn't that means our increasing hatred of fat represents a social, psychological, and moral problem rather than a medical one.

The convergence of economic interest and psychological motivation helps ensure that, for example, when former Surgeon General Koop raised more than $2 million from diet-industry heavyweights Weight Watchers and Jenny Craig for his Shape Up America foundation, he remained largely immune to the charge that he was exploiting a national neurosis for financial gain. After all, "everyone knows" that fat is a major health risk, so why should we find it disturbing to discover such close links between prominent former public health officials and the dietary-pharmaceutical complex?

The issue isn't fat, but fitness. Problem is, though we all "know" a sedentary lifestyle and junk food diet are unhealthy, we spend our time combatting what we perceive as the aesthetic end point of such habits, not the root causes. And then, through diet pills, eating disorders, and neuroses, we try to slim down without shaping up.

So what should we do about fat in the United States? The short answer is: nothing. The longer answer is that we should refocus our attention from people's waistlines to their levels of activity. Americans have become far too sedentary. It sometimes seems that much of American life is organized around the principle that people should be able to go through an average day without ever actually using their legs. We do eat too much junk that isn't good for us because it's quick and cheap and easier than taking the time and money to prepare food that is both nutritious and satisfies our cravings.

A rational public health policy would emphasize that the keys to good health (at least those that anyone can do anything about--genetic factors remain far more important than anything else) are, in roughly descending order of importance: not to smoke, not to be an alcoholic or drug addict, not to be sedentary, and not to eat a diet packed with junk food. It's true that a more active populace that ate a healthier diet would be somewhat thinner, as would a nation that wasn't dieting obsessively. Even so, there is no reason why there shouldn't be millions of healthy, happy fat people in the United States, as there no doubt would be in a culture that maintained a rational attitude toward the fact that people will always come in all shapes and sizes, whether they live healthy lives or not. In the end, nothing could be easier than to win the war on fat: All we need to do is stop fighting it.

That bit about genetics isn't nearly so certain as Campos suggests, but his general gist is sound. America is an unhealthy society, and that has helped make us a fat one. But from a public health standpoint, the problems are too much time at a desk, too much processed food, too many hours at work, too little walking, and a host of other socio-cultural-political elements that incentivize poor habits, not our waistlines.

January 2, 2007 in Health and Medicine | Permalink


"The New Republic has a fantastic article attacking the obesity myth."

Not a sentence calculated to convince me to take this post seriously, especially when followed by the logically silly 'being slightly "overweight" (at least according to the useless Body Mass Index)'. Neither is the "psychological truth" stuff. And even under the best case for this argument, the correlation isn't something random.

Posted by: rilkefan | Jan 2, 2007 1:59:43 AM

You left out a culture of instant, painless fixes. Walking around for a few hours a week is hard work. Taking some pills or having surgery is easy.

Posted by: craigie | Jan 2, 2007 2:00:17 AM

But given that the foundation of the health argument is the percentage of the population who's overweight as measured by the BMI, there's nothing silly about that sentence at all. As for the TNR bit, good work is good work no matter where it's published.

Posted by: Ezra | Jan 2, 2007 2:38:43 AM

EK: "there's nothing silly about that sentence at all."

Nonsense: see below.

"the percentage of the population who's overweight ... "

Here you've forgotten the question-begging scare-quotes and the polemical "slightly" after "obesity", and you're still apparently refusing to discuss the obvious rejoinder, "What about reasonable metrics"? The sentence is just GIGO.

Posted by: rilkefan | Jan 2, 2007 2:52:30 AM

Don't know what "GIGO" is, but I think you're missing the point of Campos's article. We're constantly told that America is overweight on the BMI, and thus wildly unhealthy. He's arguing against the usefulness of that metric, or indeed the linkage between weight and health. I get why the sentence is confusing and will edit it, but I think you sohlud read his arfticle if you haven't already. There's a piece on the media's use of the BMI, and another on the epidemiological evidence between weight and health. Both are useful, if for slightly different reasons.

Posted by: Ezra | Jan 2, 2007 3:02:57 AM

I face the scorn towards fat women all the time (being one), and I can say a few things about it in regards to activity levels. I work out pretty regularly, and walk often. I love to hike, love to bike, love to swim, love to dance (as long as I don't get too many assholish comments). I eat reasonably well, not perfectly, but better than many people I know. I'm still big. I'm the exact same shape as every other woman in my family - we are skinny kids, and tall, round women.

Yet no one is ever willing to believe that I am not a couch potato. I love being at the gym and having a skinny woman get on the elliptical next to me, thinking she'll make herself look good by being next to the fat chick. I love watching her face change as she realizes that yes, I can do this for longer than she can. Most of the thin people I know don't do anything to stay that way - they just are. Usually just like their parents and siblings. I usually eat less than they do. And no, most fat people don't eat constantly and move not at all; they have average American diets and lifestyles. Fat people aren't all slugs. ow many skinny people do you know that live on junk food and get most of their exercise from a video game console? I know lots of them.

I hate switching doctors because I get all of the unhealthy "OMG you're going to drop dead on the way to the car!" crap - right up until they get the results of my physical. Blood pressure, lipid panel, all right in line. Resting heart and respiration rates, textbook normal. No history of diabetes or heart disease in the family. No serious health problems beyond severe allergy to freakin' cedar and juniper pollen, and a creaky knee from an incident with rollerblades and a rose bush. I feel almost guilty watching them fumble for a new reason to lecture me about my weight. I know more than one fat woman who avoids the doctor entirely because of the constant barrage, condescension, and lack of listening. I went to a doctor once for persistent laryngitis, and got a weight lecture. She got a post-it note telling precisely how fired she was.

Some people eating healthily and exercising will lose weight. Most a modest amount (10% is about most people will under non-starvation circumstances). Many people will not. They will become more fit - and that's what we should be focusing on. Being a size six doesn't make you healthy. Using your body is what helps keep it healthy.

Of course, encouraging activity and a sane diet including real food, and not obsessing about the scale would kill a massive industry. And take away something that people love to feel superior about.

Sorry for the rant here. I've been reading the threads on revamping the health-care system, and have read over and over that people don't think I should be insurable, or should have to pay more than they do because I weigh more. It's bunk. People can be healthy or unhealthy at any weight.

Posted by: cellar door | Jan 2, 2007 4:13:14 AM

I doubt there is any doubt that we don't get enough physical exercise on average across the population. Any we probably consume to many calories and don't burn off enough to stay slender - irrespective of so-called junk food.

But the medical evidence on the healthy benefits of being slim/slender seems more than persuasive to me, but I'm not a professor of Law, as Campos is, (and the author of a book with the title of ""The Diet Myth: Why America's Obsession with Weight is Hazardous to Your Health." - a fact not disclosed in the New Republic Article). Example: being overweight is a high predictor of diabetes (type 2 - adult onset), and the ages of diabetes patients is going down substantially in recent years.

So maybe BMI is not perfect, but it is easy to calculate and therefore doesn't cost what a cardio-pulmonary evaluation does. Maybe it needs to be adjusted to reflect that on average Americans are bigger, eat better, and are more healthy than we have been historically.

In a 2005 press release published by the Univ of Colo, citing Campos' work, a revised figure of overweight associated premature deaths is cited from a more recent JAMA study, down from 400,000 to 25,000 per year. But note the title of the press release: "New JAMA Study Confirms CU Law Professor's Controversial Thesis On Dieting And Obesity". Yes it is controversial.

So, there is some backing for Campos' position, but surely the opinions of those doing care and research (not funded by the diet industry) would be more persuasive to me - and I've followed some of this research enough to convince me that Campos' advice is far, far to simplistic.

I'm frankly surprised, Ezra, that you would jump into the middle of a very complicated discussion about weight and health on what seems like the evidence of a single article attacking BMI by a Law Prof.

The weight gain/loss issues are very complicated, and new discoveries are being made increasingly often that suggest that very subtle genetic and metabolic regulatory mechanisms controlled by hormones (and even bacteria!) are at work. And all fat isn't the same: distribution on the body has medically significant consequences.

I don't doubt that the 'diet industry' is bad for our health, it is just the inevitable result of legally allowing companies that make non-FDA approved drugs to so obviously make health claims at the same time that they make no health claims. That's the result of a big industry (and Sen. Hatch R-ID) steam rollering Congress, and needs legislative attention and correction.

For a professor of Law to say: In the end, nothing could be easier than to win the war on fat: All we need to do is stop fighting it. , leaves me feeling angry when considering how many people will disregard medical advice and take the Campos's position as reliable. His position deserves just about as much attention as one should give to a Law Prof on any topic relating to medicine and medical statistics. That is very little, to none.

I'm not comforted either by Campos appearing on Bill O'Reilly's Fox News program talking about Ward Churchill either: something doesn't smell right about this guy.

A more nuanced view of obesity (this time in the context of the black American community - a group that Campos apparently specifically cites) is discussed here by a PhD/MPH who is Professor of Epidemiology, Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine.

The author says: There have always been naysayers about the importance of obesity to health. Nevertheless, I was shocked to hear Paul Campos, author of The Obesity Myth (10), invoke data on the lack of association between obesity and mortality among black women to buttress his case that the current level of public health attention to obesity is misguided (11). I knew the data to which he referred and strongly disagreed with his interpretation.

Well, anyway, some scepticism seems in order by us laymen.

Posted by: JimPortlandOR | Jan 2, 2007 6:18:04 AM

Don't know what "GIGO" is,....

"Garbage In, Garbage Out".

Posted by: Thlayli | Jan 2, 2007 6:49:45 AM

Ezra, any article in TNR should be presumed false until proven true.

Posted by: Barry | Jan 2, 2007 9:08:36 AM

Humans come in different shapes and sizes. That said, all human bodies are designed to move around, not sit indoors day in, day out. If you set aside the ridiculous stick-figure ideals pushed by Hollywood and TV, a reasonably fit, healthy body (not necessarily a skinny one) is available to virtually anyone for little or no cost. The process isn't that complicated--it's pretty obvious stuff, really--but no-one wants to hear it. Go for a walk after dinner (if possible) or anytime you can, for at least 30 minutes (an hour is better), at least four times a week. Eat more vegetables and fruit; view things like chocolate, butter, alcohol, and rich food as treats and have them occasionally rather than every day. Learn to differentiate real, body-hunger and bullshit emotional hunger, and treat the two accordingly: for the first kind of hunger, feed yourself nicely, with something you really want to eat, and stop when you've had enough, even if it means leaving food on the plate. For the second, ask yourself what you really need (easier said than done): a phone call to a friend, a hot bath, a nap, a switching-off of telephones, a James Brown CD and half-an-hour of dancing around the living room with no-one watching. And do that instead of the emotional eating.

My husband and I have seen, and often discussed, the moving vs. non-moving thing at Florida's amusement parks. Kids of various shapes and heights can be observed running around everywhere, thrilling to all the sights and rides, but what is worrisome is seeing so many extremely heavy children sitting almost motionless on benches, eating frighteningly large servings of fried things. If there is a study somewhere that says these kids aren't at risk, I'd like to see it.

We need to bring daily Phys Ed and recess back to our schools.

Posted by: litbrit | Jan 2, 2007 9:56:13 AM

This article was very encouraging. When I was in high school I tried to get to my ideal weight by running and eating less, and although I felt more energetic, it seemed like it was having no effect, and I gave up. Now, I've been doing the same thing, because feeling more energetic, as well as being able to run more and more, IS the effect. Losing weight is a side effect that should not be a goal.

Posted by: Cryptic Ned | Jan 2, 2007 10:09:28 AM

I always get a laugh out of the "ask your doctor if cultural hysteria is right for you" response. First, lots of health professionals agree with the position that we're suffering a moral panic over fat, rather than an actual health crisis. See, for example, the article on this in the June 2005 edition of Scientific American by Wayt Gibbs, which was just updated last month. For a detailed epidemiological critique of this issue, see my article in the February 2006 issue of the International Journal of Epidemiology, co-authored by Paul Ernsberger, a professor of nutrition and medicine at Case Western Reserve, Glenn Gaesser, a professor of exercise physiology at the University of Virginia, Eric Oliver, a professor of political science at the University of Chicago, and Abigail Saguy, a professor of sociology at UCLA.

Second, the "medical professionals" who are at the forefront of pushing obesity hysteria are usually people who have an enormous economic interest in doing so, because they're selling diet products.

Third, I would hope that people on a progressive blog would consider just why the public health establishment and the media are spending so much time focusing on the very weak correlation between weight and health, rather than on, say, the vastly stronger correlation between not having health insurance and increased medical risk.

Anyway, I should also point out the article Ezra links is four years old. A lot of stuff has been written on this since then, including my book (The Obesity Myth in hardcover; revised as The Diet Myth in paperback), Eric Oliver's book Fat Politics, Michael Gard and Jan Wright's book The Obesity Epidemic, and many monographs and articles calling our hysteria about fat into serious question.

Posted by: Paul Campos | Jan 2, 2007 10:12:50 AM

"We're constantly told that America is overweight on the BMI"

We're constantly being told that the BMI is an imperfect measure (typical article examples: Arnold and Bush): it's not news. Or e.g., from the CDC, which believes the "myth",

BMI is used as a screening tool to identify possible weight problems for adults. However, BMI is not a diagnostic tool. For example, a person may have a high BMI. However, to determine if excess weight is a health risk, a healthcare provider would need to perform further assessments. These assessments might include skinfold thickness measurements, evaluations of diet, physical activity, family history, and other appropriate health screenings.

Good for you for rewriting the sentence, but you're still conflating "obese" and "overweight" by following up the first sentence with the second, and it still makes no sense. As it stands the post sounds a lot like global warming denialists who say the local temperature is going down.

Posted by: rilkefan | Jan 2, 2007 10:43:43 AM

I'm with both rilkefan & cellar door.

On the one hand, cellar door (& Ezra) are absolutely correct. You can be healthy and "not thin" at the same time. No doubt about it.

On the other hand, rilkefan is absolutely correct: "not thin" and "obese" are two different things. cellar door is wrong when she says, "People can be healthy or unhealthy at any weight."

Really? Any weight? So if I'm 500 lbs, it's possible that I'm still a perfectly healthy human being? Unlikely.

BMI is an imperfect tool, but a tool nonetheless.

Regardless, I don't see how anyone, particularly scientists and health professionals, could argue with the general tenor of the article that the emphasis needs to be on people getting and staying fit, not getting and staying thin.

In a way, the whole selling of the "obesity epidemic" is just another aspect of our irrational obsession with quick fixes and surface appearances. If we could just all stop being fat, we'd be fine and could continue doing everything we want.

Instead we should be talking about an "unfitness epidemic" or something. Maybe a "sloth epidemic?"

Posted by: Adam | Jan 2, 2007 11:01:58 AM

People love statistics. So what do you make of this one? Smokers constitute the thinnest population in America. Former smokers constitute the fattest population in America. And never smokers are somewhere in between. So should we encourage our citizens to smoke? Maybe. Statistics show that, especially for women, being thin gives women a huge economic advantage, perhaps enough to allow them to afford health insurance and certainly enough to reduce stress, which is also a health risk. Just don't quit smoking.

Posted by: Paula | Jan 2, 2007 11:03:02 AM

It is a good article, but it's worth noting that it's also four years old.

Posted by: TS | Jan 2, 2007 11:17:17 AM

Ezra, Rilke, Cellar:
Thanks for the good discussion here, but can't the truth be somewhere in the middle? I agree w/ Rilkefan that you underrate the problem when you referred to it as "obesity hysteria", and then link it to the BMI. Pointing out the faults w/ the BMI is a red herring...I think most reasonably-informed folks now realize it's at best a rule of thumb. Clinging to its faults to then cry "hysteria" reminds me of the people who will cling to some obscure / out-of-context reference to the health "benefits" of butter or eggs or something to justify their unhealthy overindulgences of same. Same with the financial benefits gained from the diet industry. True? Of course. But not relevant to the overall solution. Those on other side of the issue point to the billions spent by Pepsi and McDs on advertising their partially hydrogenated sugar. True? Of course, but at best mildly relevant to the overall solution. We need to admit that obesity is a wide-spread and serious problem in this country, and that weight is "a" (not the) factor in a person's health & wellness.

At the same time, Ezra and CellarDoor make great points that a healthy lifestyle - that includes exercise - with smart dietary choices is a much greater determinant of someone's health than their weight. I cringe at the prejudices and stereotypes that CD has to endure, and hope that we evolve past those.

That said, I do think our knowledge and sophistication around this whole issue is evolving in this country. First we were basically oblivious. Now as we learn more we'll make some mistakes, develop better strategies and get a better perspective on what makes healthy people.

I'm focusing on the common ground between your debate above, not the differences. Thanks again!

Posted by: Rareflight | Jan 2, 2007 11:20:29 AM


That you can't understand the point Ezra is making and the idea that he's not making sense are two different things.

I'm surprised at the response this post is getting. Neither Ezra nor Paul are suggesting that Americans should eat fried Twinkies 8 times a day and use motorized scooters to get from the kitchen to the TV room.

Instead, they seem to be saying that where one carries "extra" weight is perhaps more important than the amount by itself. And, as has been suggested, perhaps it is more important to have a healthy heart, decent blood pressure and cholesterol that isn't off the charts than it is to conform to a standardized test that we can take on the internet.

Really, people, the BMI purports to assess a person's obesity using only one's height and weight, applying the exact same test to both men and women. I guarantee that every offesive lineman in the NFL is, according to the BMI, so obese they are all in danger of FALLING DOWN DEAD RIGHT NOW!!! Yet they somehow manage to keep going.

Arguing for a sensible approach to issues of weight in a culture that worships the ultra-thin is not radicalism. And in 2007 we should certainly ask for diagnostic tools that are better than the BMI.

Posted by: Stephen | Jan 2, 2007 11:21:09 AM

Oh, the fatness flamewar. I sure didn't see this coming from a mile away.

Posted by: Sara | Jan 2, 2007 11:54:42 AM

When I was caring for my aged mother, I had to work at keeping her weight up. At a certain age, the physicians informed me that patients have a higher survivability if they have a twenty pound cushion. I calculated that the thin "ideal weight" for her was 120 lbs. so I tried to keep her weight at 140 lbs. That way, if she were hospitalized, which often leads to rapid weight loss, she would not starve to death. It was hard enough with my mother, who was always overweight, and always loved to eat, to get her weight up as her appetite diminished. Among the elderly who have always been thin, one bout of diahrrhea can kill them.
I bring this up, because when we're talking longevity, we are really talking gerontology. Most Americans don't keel over at 50.

Posted by: Paula | Jan 2, 2007 12:01:37 PM

Just because its relevant, the longest-range study on body mass and life expectency came out in November, and it concluded, among other things, that thin people lived longer (although it also measured other variables).

And as an aside, it is difficult for me to believe, as some of this discussion has suggested, that some people are simply "fatter" than others. If you burn more calories than you consume, you will lose weight, and vice versa. The extent to which being overweight will exacerbate health problems one is genetically predisposed to is, of course, another matter.

Posted by: PW | Jan 2, 2007 2:21:55 PM

Paula makes an excellent point about geriatrics and weight. After age 65 high BMI has no predictive value for increased mortality risk, while lower BMI levels correlate with much higher mortality. Since currently 80% of all deaths are among people over the age of 65 this isn't an academic point.

PW finds it hard to believe that some people are simply fatter than others. Is it hard to believe some people are simply taller than others, or more freckled than others, or darker-skinned than others? It's quite common for some people to have twice as many fat cells than others, and the number of fat cells a person has is genetically determined and not alterable.

We have now reached a point on this issue in which the conventional wisdom is that everybody would fall within a fairly narrow range of body mass if everyone had the same lifestyle (hence the public health establishment's bogus definition of "normal" weight as being between 108 and 145 pounds for an average-height woman). This is completely unscientific and flies in the face of everything we know about what produces different levels of body mass in different individuals.

We simply don't know how many people would be "overweight" (sic) if everyone had a healthy lifestyle, even assuming we could specify what a healthy lifestyle for everyone would consist of (and of course it wouldn't consist of precisely the same thing for every individual by any means).

Posted by: Paul Campos | Jan 2, 2007 3:17:54 PM

I thought it was well established that the sedentary lifestyle that often leads to being overweight-and not necessarily being overweight itself-was the real health problem in America. This doesn't sound like much of a revelation to me, though perhaps I'm missing something.

Posted by: Xanthippas | Jan 2, 2007 4:12:59 PM

"Really? Any weight? So if I'm 500 lbs, it's possible that I'm still a perfectly healthy human being? Unlikely."

That is most certaily correct. I have never known anyone in person that heavy, and would imagine that weight like that would be a combination of lifestyle and underlying disorder somewhere. I don't know enough about extreme obesity to hazard anything other than uneducated guesses.

My main point is that the spectrum of healthy weight is much broader than currently defined, and that BMI is an awful indicator of health. Was it what, four or five years ago they downscaled the healthy BMI, leaving all the women's rowing team at Yale suddenly overweight? You can't determine someone's health by a height/weight ratio. It's nuts.

Posted by: cellar door | Jan 2, 2007 5:01:28 PM

PW said, " If you burn more calories than you consume, you will lose weight, and vice versa." But this is not entirely correct. Consuming fewer Calories than one burns will lead to fat loss. Muscle tissue is approximately 4 times the density of fat tissue, so when muscle is built and fat is lost, a person can gain or maintain their weight, while still becoming thinner. My friend stayed the same weight and dropped three dress sizes when she took up hockey.

I take care of myself by eating healthful foods and walking 2 miles a day. I don't let my weight define my worth as a human being, but it's a trap that is so easy for people to fall into when looks are presented as a woman's primary assets in most magazines and tv shows that can define what's "hip". In the popular media, it is taken as a given that thin = beautiful. And we all want to be beautiful, right?

I had one year of a gym class called "personal challenge" which was about building teams and cooperating in activities that used both our brains and our bodies. It's the only gym class I ever took that wasn't about performance in team sports, and the only one I haven't loathed with a passion. Phys Ed needs to be about helping everyone find physical activities they can enjoy (including dancing, gardening, and walking) rather than how well we can play kickball or dodgeball and how fast we can run a mile.

Posted by: Denise | Jan 3, 2007 12:48:26 AM

The comments to this entry are closed.