What's Behind New Findings That It's Healthy to Be Overweight?
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Did you hear the news? Now it’s healthy to be fat! It turns out that your smug skinny friend who eats broccoli and runs marathons should have been eating fast food and watching TV this whole time. Right?
Well, maybe not. A new study published in the Journal of the American Medical Association has made headlines because it found that overweight people have lower mortality rates than people with “healthy” weights and that even moderate obesity does not increase mortality.
This means that an overweight 5’4” woman weighing between 145 and 169 pounds (Body Mass Index of 25 to 29) has less chance of dying than a woman of the same height who weighs less. If she gains weight and falls within the lower obese range (174 to 204 pounds, BMI of 30 to 35), she is equally likely to die as a woman with a “healthy” BMI of 18.5 to 25. Only once her weight exceeds 205 pounds does her risk of mortality increase.
The study made waves when a recent New York Times op-ed proclaimed that “baselessly categorizing at least 130 million Americans — and hundreds of millions in the rest of the world — as people in need of ‘treatment’ for their ‘condition’ serves the economic interests of, among others, the multibillion-dollar weight-loss industry and large pharmaceutical companies.”
So what’s the story? Is it healthy to be overweight?
As usual, it’s instructive to look back in history – in this case to the mid-1990s when the current standards we use to define “overweight” and “obese” were set. Initially, the U.S. government used a BMI of 27.3 for women and a BMI of 27.8 for men as the lowest BMIs that qualified as overweight.
Across the pond, British scientist Philip James convened the International Obesity Task Force in 1995, and their work, in collaboration with the UN’s World Health Organization (WHO), led to an international standard that defined a BMI of 25 or above as overweight for both sexes, and a BMI of 30 or above as obese.
Back in the U.S., the National Institutes of Health put together an expert panel, chaired by Dr. F. Xavier Pi-Sunyer, a recognized expert on obesity, and at the time, the executive director of the Weight Watchers Foundation. In September 1998, they published a document called the “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” which lowered the U.S. standard for overweight to match the international standard.
Suddenly, a 5’4” woman who weighed 145 or a 5’10” man who weighed 174 were considered overweight. Newspapers published articles on 29 million Americans who went to bed at a healthy weight one night and woke up the next morning to discover they were overweight – although they had not gained one single pound! At the time, these previously “healthy weight” individuals accounted for nearly 30 percent of the overweight and obese people in America.
In the mainstream media, one of the few opposing voices to this change was former Surgeon General C. Everett Koop, who told the Washington Post that, “weight does not increase the risk of death until the BMI reaches 27 or 28.” Other critics feared that the new standards would result in an increase in the use of diet drugs or discourage Americans, resulting in them giving up trying to lose weight altogether.
Others point to conflicts of interest among the expert panel that defined 55 percent of the nation (at the time) as overweight or obese, or even data showing that a few extra pounds did not result in increased mortality.
To truly get to the bottom of the issue, one must consider the conflicts of interest on all sides. For example, Pi-Sunyer was tied at the hip with Weight Watchers, he was director of a weight loss clinic, and he served as an advisory board member or paid consultant to several pharmaceutical companies that made diet drugs. Similar accusations have been lobbed at Philip James in the U.K. But on the other side of the coin, nearly every industry in the U.S. – with the exception, no doubt, of the airlines – makes handsome profits from an overweight and obese populace that is desperate to lose weight but continually fails to do so.
Consider a typical American who spends money on large amounts of processed foods at grocery stores and restaurants, and then needs to buy clothing in larger and larger sizes. She even requires more gas to transport her extra weight, and perhaps she and her partner decide they need a larger bed. Desperate to slim down, she enrolls at a gym, buys diet books, special diet foods, and perhaps even weight-loss drugs. Maybe she loses some weight. Maybe she doesn’t. But even if she succeeds temporarily, in all but a minority of cases, the weight is back again within a few years and she starts the cycle again. How much money does she spend to get fat and then get thin again?
The industries that sell junk food want Americans to continue buying their products, of course. Many corporations like Coca Cola, Wendy’s, Applebees, and Outback Steakhouse fund the so-called Center for Consumer Freedom, which runs the Web site ObesityMyths.com. Visit this site to learn why you should continue drinking Coca-Cola and eating at Applebees without worrying about what the food police tell you. The site devotes a special section to “Myth-Makers” like Philip James, accusing him of conflicts of interest. Often with flimsy evidence, these myth-makers are tarred as being financially tied to the diet drug and weight-loss industries, with the implication that their work lacks credibility because they are being paid off to talk about the global scourge of obesity.
A more reasoned assessment of James’ and Pi-Sunyer’s conflicts of interest comes from University of Chicago professor J. Eric Oliver, who first points out in his book Fat Politics, “It is difficult to find any major figure in the field of obesity research or past president of the North American Association for the Study of Obesity who does not have some type of financial tie to a pharmaceutical or weight-loss company.” He goes on to acknowledge that, “While the pharmaceutical industry did not necessarily dictate the decisions of the obesity experts, the conflicts of interest among the leading researchers in the obesity field are both undeniable and problematic.”
Oliver calls out a “health-industrial complex” which is “built upon a symbiotic relationship between health researchers, government bureaucrats, and drug companies.” Each group relies on the others to get what they want, be that drug sales, congressional funding for their government agencies, or prestigious appointments, recognition and lucrative speaking gigs. For each group, adding tens of millions of Americans to the population at risk due to obesity helps them toward their goals. That isn’t to say that self-interest was the determining factor in their decision to lower the BMI considered overweight to 25. But it’s a possibility that self-interest played a role.
In any case, that’s how we got to where we are, with anyone over a BMI of 25 thrown into the “fat” category. But the “news” that being overweight might not increase your risk of mortality is not actually news. The same researcher at the CDC, Katherine Flegal, came to just that conclusion eight years ago, which she explained at length in Scientific American in 2007. Even back in the 1990s, there were already some studies with conclusions similar to Flegal’s available to the experts setting the weight at which one is considered overweight or obese.
Then and now, these studies provoke some controversy. For one thing, smokers often gain weight when they quit smoking – but quitting smoking is a healthy thing to do. Also, many who are terminally ill are thin and frail – but not healthy! The studies attempt to correct for these issues as much as possible.
Furthermore, as medicine advances, humans are able to live longer with chronic disease. The studies use mortality as their measure, but “not dead” does not indicate that one is healthy. Some even suggest that overweight people might enjoy lower mortality because their doctors screen them for more problems due to their high weights compared to patients with lower weights.
Deb Burgard, an eating disorders specialist, says that Flegal’s conclusions make sense, because so many Americans die of diseases that cause them to lose weight while they are ill. An elderly person who has a bit more meat on his or her bones at the beginning of the illness can tolerate the weight loss with less harm to their health.
Linda Bacon, author of Health at Every Size, points to other possible discrepancies in our understanding of obesity and health. For one thing, correlation is not causation. Just because many people with a certain disease are also fat, that does not mean that one caused the other. In her book, she points to some evidence that type II diabetes causes obesity, not the other way around.
She also questions the impact of “weight cycling” (repeatedly gaining and then losing weight) on ones’ health. She says, “weight fluctuation is strongly associated with increased risk for diabetes, hypertension, and cardiovascular diseases, independent of body weight.” As many overweight people try to lose weight – sometimes via extreme diets – could the impact of weight cycling confuse our understanding of the health impact of obesity?
Her most convincing point is that sedentary lifestyles and poor eating habits can cause both health problems and overweight or obesity. And in fact, Bacon does not encourage readers to sit back and eat endless amounts of junk. She instead counsels them to pay attention to their bodies’ signals, eating only when hungry and stopping when full. Don’t eat while doing other activities. Pay attention and enjoy your food. Eat whole foods, mostly plants. And be active – but find an activity you enjoy!
Burgard, who worked with Bacon to develop the Health at Every Size model, deals with the fallout of our fat-phobic culture. Whether for health or for beauty reasons, a huge percent of Americans now hate themselves every time they look in the mirror.
“Lots of women wake up in the morning and look in the mirror and say I feel so fat, even though fat's not a feeling,” says Burgard. “It's a code word for ‘I feel ugly, I feel vulnerable, I'm going to get rejected socially.’ In our culture, that gets connected up to fatness. And so what's fascinating about this is that when people's bodies change, it's not going to be the case that they lose their identification with that part of themselves that feels vulnerable, that feels like a loser.”
Often, she finds people with eating disorders try to lose their feelings of vulnerability by losing weight. The pounds may disappear, but the feelings remain. The person tries to lose even more weight to see if that will do the trick, but it never does.
One reason Burgard dislikes the national war on obesity is because it influences people to distrust their appetites. She says, “When people look at their body size, they have this mythology that everybody who eats ‘normally’ has a thin body and if you don't have a thin body, you must not be eating the right way. It makes you distrust your appetite. They think, ‘If you did the right thing you would be thin.’ This is the biggest myth of all.”
By focusing on weight instead of healthy habits, one is pushed toward the wrong goals. Brand-name diet foods are not always healthy, and extreme starvation diets never are. At the same time, weight-as-a-measure-of-health sends a signal to “normal” weight Americans that they are doing everything right and don’t need to change. But healthy diets, regular exercise, good sleep habits, and stress reduction are good for everyone, no matter their weight.
Additionally, the stigmatization overweight people face is 100 percent destructive. In addition to the stress and feelings of shame it engenders, it even drives some people to avoid going to the doctor. Burgard reports that patients tell her they avoid going to the doctor for as long as possible – skipping routine physicals and gynecological visits – because they don’t want a lecture about their weight.
She has strong words for the weight loss industry -- which she calls the “weight cycling industry” -- saying, “That's what happens and that's the way they make money.” While some people who lose weight do keep it off, she says they are as rare as people who win the lottery. “OK, they exist,” she says, “But if I'm a health care provider, if I know that 98% of the people I send down this road will end up sicker, physically and psychologically, why would I do that?”
Burgard continues, “If you look at the last year, you look at the number of African American and male spokespeople for these companies – there's an explosion of marketing to these communities now – and what we're seeing in the eating disorder community is that the number of boys with body image concerns are going up and up and younger and younger kids are having these concerns. So the eating disorder world and the obesity treatment world are really at odds.”
After several months trying to lose weight or keep weight off and failing, many end up in Burgard’s office. “We see people who are in dire straits for one reason or another. We see the fallout. We have to speak up because the people who treat obesity have such terrible followup and they blame their patients or their customers for the interventions not working, which is completely unfair and wrong. And they need to understand the suffering that they are causing.”
In other words, the new study with not-so-new conclusions does not mean that you can kick back and eat as much junk as your belly can hold – but it does mean we should question the national obsession with losing weight. It also means we should question the motives of the “experts,” whether they are having their bread buttered by the weight loss and pharmaceutical industries or they are working on behalf of junk food companies.