Fraser, who conducted this informal survey as part of the research for her recent book “Losing It,” wasn’t surprised to be termed fat. That’s how a Kate Moss-driven world sees the rest of us. But she was appalled at how many medical professionals simply ignored the clear evidence of her physical well-being. “To say that overweight causes health problems isn’t true,” she says. “It can be a marker for an unhealthy lifestyle–if you’re sedentary and you eat junk food, you’re apt to be fat. But when you look for what’s wrong with obesity itself, you come up with issues involving culture and society-not health.”
Not health? When doctors and scientists for years have targeted overweight as a risk factor for heart disease, diabetes and cancer? When C. Everett Koop, former U.S. surgeon general, has launched what he calls a “great crusade” to fight obesity, which he blames for more preventable deaths than anything except smoking? But according to an increasing number of authorities, much of the longstanding gospel about fat is due for revision. Many experts now question whether obesity really is a death sentence, whether weight loss really does contribute to longevity, even whether weight is a useful measure of health. “All the studies just don’t agree,” says Dr. Reubin Andres, clinical director of the National Institute on Aging, whose work has shown that adults who fatten up a bit as they age live longer than those who lose weight. “Either obesity is the greatest health hazard of the developed world, or else your weight doesn’t matter too much, provided you’re not too lean or grossly obese.”
There’s no disputing the growth of the national paunch. In 1980, according to government surveys, about a quarter of all adults were too fat for their height; today it’s a third. One recent analysis, which set the cutoff point for a healthy weight a few notches lower in accordance with international standards, found that 49 percent of American women were overweight and 59 percent of men. Writing in the British medical journal The Lancet, Drs. John Foreyt and Ken Goodrick of Houston’s Baylor College of Medicine calculated that by the year 2230, the entire adult population of the United States would be overweight. (“It was tongue-in-cheek,” admits Foreyt.) But Foreyt has a refreshing new message for diet-crazed Americans. “I always tell my patients ‘Get a life’,” he says. “Focus on healthy eating and more physical activity. Don’t worry about your weight so much.”
The doomsday message about fat is based on numerous studies showing an association between gaining weight and piling up risk factors for several diseases. By all accounts the most powerful association is with adult-onset diabetes, rates of which are increasing “astronomically,” according to Dr. JoAnn Manson of Harvard Medical School. Excess fat tissue, says Manson, is strongly related to insulin resistance, the metabolic condition that can prompt diabetes. According to Koop’s group, prevention of obesity among middle-aged people could cut their incidence of diabetes nearly in half. Studies have also documented links between overweight and high blood pressure, high cholesterol and high triglycerides–frequent precursors of heart disease. “About half of us die from atherosclerosis, and obesity plays an enormous role in how we got there,” says Dr. William Castelli, former director of the long-running Framingham Heart Study.
Yet studies have not demonstrated with any consistency that obesity per se–apart from such related conditions as high blood pressure or high cholesterol-is a risk factor for heart disease. The cause-and-effect relationship is far less clear than it is with diabetes. “What we suffer from in our society is the ‘Casablanca’ syndrome: round up the usual suspects,” says Glenn Gaesser, an exercise physiologist at the University of Virginia and author of “Big Fat Lies.” He believes poor diet and lack of exercise are the culprits-bad habits that exist right across the spectrum of weights.
Some of the most dramatic evidence for the need to rethink health and weight comes from research carried out by Steven N. Blair and his colleagues at the Cooper Institute for Aerobics Research in Dallas. They followed 25,000 men for an average of eight years, beginning with a physical exam and a treadmill test to establish their over-all health and fitness. In general, the fatter the men, the worse their cholesterol, triglycerides and so forth. And the fatter men tended to do less well on the treadmill. Sure enough, by the end of the study period, the fatter men had the highest death rate. But when the participants were grouped by fitness category, it became clear that the men who did best on the treadmill test-no matter what their weight-had the lowest risk of death. Even the relatively few men who were physically fit and obese had a lower risk of death than the unfit men of normal weight (chart).:
Harriet Coffey has her mind on fitness these days. A deejay for a Charlotte, N.C., radio station, Coffey likes her size just fine, though she and her doctor agree she’s about 40 pounds overweight for her 5 feet 5. But a year ago she was diagnosed with high blood pressure, and recently her blood sugar has risen, too. So she’s started to eat less, watch her fat intake and work out on an exercise machine. Her goal isn’t weight loss, it’s to fend off the health problems for which she’s at risk, especially diabetes. “I can’t stand the thought of giving myself needles,” she says.
Fat-and-health revisionists believe that too many Americans are being bamboozled by weight charts and bathroom scales. For years, doctors used the Metropolitan Life insurance company’s height-weight tables; now the gold standard is the more sophisticated BMI, or body-mass index. (You can compute your BMI in a flash by dividing your weight in kilograms by the square of your height in meters. OK, you can also click into http://www.shapeup.org/sua, the Koop group’s Web site, and it’ll do it for you). Doctors who use BMI generally advise people not to exceed 25 (that’s 5 feet 4 and 146 pounds, for example). A BMI greater than 27 (5 feet 4, 158 pounds) is approximately where overweight tips into obesity, and health problems may accumulate. Everyone agrees that a danger zone lurks above 27; it’s the vast area below, where many Americans wander around with 10 to 30 extra pounds, that’s in dispute.
More pertinent even than BMI is where you carry your fat (chart). Scientists now believe it’s the fat padding your waist and belly, giving you an apple shape, that does the most damage to health. Fat hips and thighs, which give you that much-maligned pear shape, may injure only the ego.. Abdominal fat is more active metabolically than fat elsewhere in the body, meaning that when “apples” store fat it’s broken down and released into the bloodstream more readily. This hyperactivity can bring on insulin resistance, high blood pressure, high cholesterol-in short, the health problems associated with obesity.
Gaesser and others say it’s important to lose excess abdominal fat, but not to worry about flabby upper arms and thunder thighs. “The majority of your weight is irrelevant from a health standpoint,” says Gaesser. “The average woman or man has about five to 141 pounds of bad body fat on them, and it’s the easiest to lose. When you start people on healthy eating and exercise, the first thing they notice is that their clothes fit better, especially around the waist.” Gaesser thinks the fairly quick disappearance of belly fat may explain a phenomenon many researchers have documented: when fat people lose even a small amount of weight, they reap extraordinary health benefits. “I’ve seen people with a five-pound weight loss cure their hypertension,” says Castelli of the Framingham Heart Study.
Of course, losing just a chunk of your fat leaves you with all the rest. And many scientists are far from convinced that benign neglect is the right attitude. “Excess body fat is definitely harmful,” says Dr. Boyd Eaton, an Atlanta radiologist who has published extensively on exercise, nutrition and disease. He cites the risk of degenerative bone disease and endometrial cancer, as well as diabetes. Manson of Harvard Medical School, whose research suggests that slimmer women have the lowest risk of premature death, says the more total fat you have, the worse off you are, no matter what your fruit type. “We’ve had a 40 percent decline in mortality from heart disease in the last quarter of a century, but that trend may be reversing,” she says. “One possible explanation is the increasing epidemic of obesity and its health risks.”
Whether or not they believe thinner is better, many researchers hesitate to recommend old-fashioned dieting for moderately overweight people. Surveys and studies have shown for years that dieting success tends to be temporary, and the return of the weight is profoundly depressing. “The question is, how much of that body fat can you do something about?” says David Levitsky, professor of nutritional sciences at Cornell University. “You can’t change your height, and in some measure you can’t change your body fat.” Levitsky believes that throughout the population, about half the variation in body size can be attributed to heredity. Given the intractable nature of so much of our shape, he calls it “unethical” for doctors to put fat people on a diet unless they show signs of diabetes, high blood pressure or other health problems.
Of all the research that questions traditional thinking on weight and diets, the most nerve-racking comes from Andres of the National Institute on Aging. He analyzed 11 large population studies in the United States and Europe to find out how changes in weight affect longevity. The lowest mortality rates, he learned, are associated with people who gain modest amounts of weight in adulthood. Gaining a great deal of weight contributes to earlier mortality-but so does losing weight, even “mild to moderate” amounts. “There’s every reason to expect the truly obese people would benefit from losing weight, but if you look at survival, not at individual risk factors, those that lose do badly,” he says. “We don’t understand why.” It’s unknown, in these studies, why or how the weight came off-was it via yo-yo dieting, was it after a single diet followed by long-term weight maintenance, or was it because of illness? Yo-yo dieting has long been suspected of being hazardous. And, of course, if illness prompts weight loss, higher death rates are understandable. But until more research can clarify the matter, it’s hard to make the case that losing weight is just what the doctor ordered, even when it is. “People show an improvement in risk factors, but they die,” says Dr. David Garner, director of the Toledo Center for Eating Disorders. “I don’t think that’s a good outcome.” David Williamson, associate director for science in the diabetes division of the Centers for Disease Control, says that for obese people with health problems-say, someone who’s already had a heart attack-dieting probably does improve longevity. But moderately overweight, aging baby boomers? “The garden-variety person like that should become substantially more physically active,” he says. “That’s the cornerstone.”
It’s the cornerstone, all right: as dieting slinks off under a cloud of disrepute, exercise moves confidently into the spotlight. “We no longer talk about losing weight, we talk about managing it-stabilizing where we are,” says Sharon Dalton, director of the graduate program in nutrition at New York University. “Exercise is the key.” Not a single expert has a bad word to say about physical activity, which apparently improves every aspect of mental and bodily health with the possible exception of gum disease. And nobody knows quite why. “We suspect there are indirect metabolic pathways whereby exercise provides protection,” says Steven Blair of the Cooper Institute. “Say you’re 45 and you’ve gotten fat, so you take up some activity. You might lose a few pounds, but the real benefit comes when you’re 55 or 60. You haven’t gained, maybe you’ve even lost a little, your health is better and you’re less likely to die.” Can’t beat that. And exercise, for Blair and the other enthusiasts, is hardly Olympic level–30 to 45 minutes a day of brisk walking will do it. Of course they all recommend healthful eating as well, but their advice is simply to follow the USDA Food Guide Pyramid-less saturated fat, more fruits, vegetables and grains.
Fit and fat! Maybe it’s not a mantra to gladden the heart of Jane Fonda, but it’s an achievable goal for the rest of us..And if you’re embarrassed to show up in a gym, you’ll know how Dee Hakala felt. “One of the scariest things for me was to go into a health club weighing 350 pounds, but my goal was just to try to do whatever I could,” says Hakala, author of “Thin Is Just a Four-Letter Word.” “At least I wasn’t sitting on the couch eating myself into oblivion.” She became such a convert to aerobics that she started teaching it, tailoring her classes to people who were too fat or out of shape to keep up with the spandexcrowd. Today she weighs 200 pounds, still fat at five feet but incredibly fit, and her exercise program-New Face of Fitness–is carried by 60 YWCAs. One of its fans is Jimmie Lu Duran, a 69-year-old grandmother in E1 Paso, Texas, who loves pork tamales. She used to have to sit on a bench and rest while her daughter shopped at the mall. Now she takes an NFOF class three times a week. She still eats tamales, but when she was locked out of her house last summer, she promptly climbed a fence and crawled in through the window. “I never would have been able to do that before this class,” she says.
Aerobics may never generate as much excitement as diet drugs (sidebar), but people who do choose sensible lifestyles tend to stick with them and, in time, reap the benefits. “I know I’ll never be a size 12 again,” says Martha DeMichele, 64, who takes an underwater-exercise class twice a week at a Chicago pool. At 5 feet 2 and 185 pounds, she watches what she eats, loves her new energy and says the diet pills and diet programs are gone forever…
But brave new nonfanatics are still in the minority. “Health, not vanity.’? That’s a tough sell in this country,” says Gaesser. TV, magazines, billboards, movies, fashion-throughout the culture, skinniness rules; and despite feminism, for women it’s more true than ever. “The idea now is a body that’s so thin it can’t menstruate, it’s infertile,” says Fraser. “Enough, already. Why do we buy this?”
Maybe we buy it because there’s not much else out there. And that’s why the sight of Alexandra Beller in action is so invigorating. Beller, a member of the Bill T. Jones/Arnie Zane Dance Company, is a gorgeous dancer and a round one–3O pounds heavier than most women dancers when she entered the company. “I’ve been on diets since! was 8,” she says. She fell in love with dancing the moment she tried it at summer camp, and although various teachers tried to discourage her, she persisted in studying jazz, ballet and modern. When she auditioned for Jones, she was one of 400 hopefuls and the only one selected. “She’s quick, light and buoyant, with a mercurial liquidity in her joints,” wrote Tobi Tobias in New York Magazine, after seeing Beller in a solo last spring.
Beller is the wrong shape in a rarefied world of ideal bodies, but her dancing breaks the mold. She looks great, and her strength of spirit glows. Sick of billboards lionizing slack-jawed teenagers with their ribs sticking out? Here’s a welcome role model for being just the size you are-and running with it.
Fitness First
A study of 25,000 men showed that those who were more fit had lower death rates–even if they were overweight.
OUT OF SHAPE: THE FRUIT TEST Scientists now divide fat people into two groups, according to body shape: apples and pears. Men tend to be apples, women pears, mostly because of hormonal differences. Women may fret more about their size, but apple fat poses the greater risk to health.
Apples. Apple-shaped people carry much of their fat above the waist. This fat is hyperactive: it breaks down and enters the bloodstream readily, which may lead to clogged arteries, high blood pressure and other problems.
Pears. Pear-shaped people carry much of their fat on hips and thighs. Some researchers call this “good fat” because it’s associated with high levels of HDL, the “good” cholesterol. Others say there is no such thing as good fat.
HOW to find out if you are an apple or a pear: Measure your waist and hips. Divide your waist measurement by your hip measurement. This is your waist to hip ratio. Check below to determine your health risk:
FOUR WAYS TO START OK, dieting is out, healthy living is in. Here are a few easy steps to get going.
Throw out the bathroom scale
Start walking As little as thirty minutes daily of brisk activity makes a difference.
Move to Hawaii. Just kidding. But after switching to traditional Hawaiian foods–including taro (a starchy root), greens, fruits and lean protein–Gov. Benjamin Cayetano and 22 other state leaders lost weight and dramatically improved their cholesterol, triglycerides and blood sugar. For a mainland version, eat a low-fat, high-fiber, veggie-rich diet.
Unwind. High levels of stress are bad for your blood pressure, heart and immune system. So practice the piano, dig in the garden or just gather up the kids and watch the stars come out.
QUICK FIX: DO DIET PILLS WORK? SUE MILLER
DIETS WEREN’T WORKING for Judy Surace, who desperately wanted to shed pounds for her health, not her vanity. So last July, weighing 188 pounds and facing serious complications from diabetes, she started taking the new obesity drug Redux. Surace has since lost 86 pounds. More importantly, says the 53-year-old hospital secretary in Cleveland, her diabetes is in check and she feels great: “It’s like I’m a new person. Redux is my miracle pill.”
Surace is hardly alone. Redux and the combination of obesity drugs fenfluramine and phentermine, known as fen-phen, have sparked a revolution in the diet industry-and together racked up sales of $400 million last year. Both help people eat less by regulating serotonin levels and promoting feelings of satiety. More than 140,000 doctors have written 3.3 million prescriptions for Redux since the drug hit the U.S. market last June. .Eighteen million prescriptions for fen-phen were written in the last year alone.
The drugs are recommended only for the clinically obese (20 to 30 percent overweight), in combination with sensible eating and exercise. But critics believe many doctors are prescribing them for patients-mostly women-who want to shed just a few pounds without making lifestyle changes. “It’s just outrageous,” says Dr. Michael Myers, who runs a weight-loss clinic in Los Alamitos, Calif. “They’re handing out these pills like snake oil.” Jenny Craig and Nutri/System Weight Loss Centers have eagerly embraced the obesity pills, incorporating them into their diet and exercise programs. And diet-pill clinics have sprung up to capitalize on the trend. Dr. Don Jensen had only four weight-loss clinics in L.A. in 1994; today he owns 18 and has about 7,000 patients, most of whom, he says, take fen-phen with good results.
But some fear the pills may be dangerous. One concern is that doctors may be playing down the risk of side effects like primary pulmonary hypertension (PPH), a rare lung disease that kills half the people who get it, and neurotoxicity, or brain damage. A spokesperson for Wyeth-Ayerst Labs, the marketer of Redux, acknowledges there’s a very small risk of PPH, but says there’s “no scientific evidence that Redux causes neurotoxicity at prescribed doses.” The FDA has received unconfirmed reports of about 1,000 adverse reactions to Redux in the first 2 million prescriptions, including 18 deaths and 26 “serious psychiatric events” such as psychosis, aggression or severe depression. These numbers don’t “raise any red flags,” says FDA spokesman Don McLearn. “At least not yet.”
A less serious but more common charge against diet pills is that many patients don’t lose that much weight. Or, if they do, they often gain it back as soon as they go off the drugs (Redux is approved for one year’s use). Jensen says about half his patients add back pounds after dropping the drugs. Surace, for one, knows that both diet and exercise are key. She asked her husband to repair her bicycle, which she hasn’t used in five years. “This spring,” she promises, “it’s coming out of the shed.”
