Body of Truth

Chapter 1

Four Big Fat Lies About Weight and Health

              “There are many core ideas within the science of body weight and health and the mediating role played by exercise and diet which are simply assumed to be true.”

—Michael Gard and Jan Wright,

from The Obesity Epidemic:

Science, Morality, and Ideology

We were sitting in my backyard, a handful of women from the neighborhood. We were eating cake, as it happened, a lemon poppy seed cake I’d made that morning, and drinking iced tea, and talking about our lives. And so it was inevitable that the conversation came around to weight—the weight we wanted to lose, the weight we’d gained, the weight other women had lost or gained, or lost and gained. A typical conversation, in other words.

One neighbor mentioned a popular TV show featuring an actress who would be too large to, say, walk the runway. “I can’t stand watching anything she’s in,” the neighbor commented. “I’m afraid she’s going to have a heart attack any minute. She’s just so unhealthy. Doesn’t she know she could drop dead? Doesn’t she know what she’s doing to herself?”

There was no chance the actress would keel over mid-episode, of course, since the show was taped. So what was my neighbor getting at? I puzzled over this for a few minutes and eventually realized that she wasn’t actually worried about the actress’s health. She couldn’t be because in fact she didn’t know anything about the actress’s health. So what she was actually talking about was the actress’s looks, not her health. My neighbor thought the actress was unattractive because of her weight, but she was too politically correct to come out and say that. Critiquing health in the context of weight, on the other hand, is perfectly acceptable in polite company. In fact, it’s almost required in some circles. As health—or at least the perception of health—has become a social and moral imperative, judging other people’s health status has become not just accepted but expected.

In his 1994 book The Death of Humane Medicine and the Rise of Coercive Healthism, Czech doctor Petr Skrabanek defines healthism as a worldview that judges human behaviors by how we think they affect health. Notice that emphasis on belief rather than reality. Behaviors we believe make people healthier—exercise, for instance—carry a sense of moral virtue; we say we’re “being good” when we take the stairs instead of the elevator, eat salad (without dressing!) for lunch, spend an hour at the gym. Behaviors we think make people less healthy are seen as unacceptable. We’re “bad” when we eat a slice of cake or binge-watch Orange Is the New Black. Restaurant owners know this; it’s why they name desserts sinful cheesecake or chocolate decadence, cleverly acknowledging and deflecting the moral judgment around eating them.

A lot of what we believe about weight and health comes from assumptions of healthism, starting with one of our most cherished truths: Fat is unhealthy. It’s a statement that’s so general, so broad, and also so deeply ingrained, it’s hard to pin down precisely what it means. It’s just something everyone knows, right?

It’s hard, in this culture, to question that statement—to even imagine a world where that might not be true. That long-ago day in my therapist’s office, I couldn’t even consider the possibility that maybe being overweight or even obese wasn’t as unhealthy as I thought. I’d spent years worrying about how my weight might affect my health, especially after one doctor sat me down and told me if I were her sister, she’d put me on a diet that very minute and make me lose weight. “If you don’t,” she warned, “you’ll wind up with heart disease or diabetes or high blood pressure, or all three.”

She didn’t have to convince me; I already believed it. I already worried about whether I was (as my grandmother often commented about others) eating myself into an early grave. I already imagined my arteries clogging each time I ate a shred of fat—actually, each time I ate anything. By the time I got home from the doctor’s office that day, panic was making me hyperventilate, which made me think I was having the threatened heart attack right then and there.

Compared with some of the stories I’ve heard from other people since then, her tactics were actually pretty mild. She didn’t, for example, refuse to treat me until I’d lost weight, or write “noncompliant” on my medical chart, or try to sell me a carton of Medifast or a Weight Watchers membership. But she did make it perfectly clear that I would never be healthy until I lost weight. (And she did insist on putting me on statins, which caused extreme muscle pain; I had to stop taking them.) Ironically (but predictably), her well-meant lecture had the opposite effect from what she’d intended. I went into such an anxious tailspin over the next few weeks that I wound up stress-eating and gaining weight.

It took a family catastrophe to make me even start to question what I thought I knew: my then-fourteen-year-old daughter developed anorexia. As I sat hour after hour in silent shock beside her bed in the ICU, the formula I’d lived with all my life without question—fat=bad, thin=good—seemed horribly skewed. Suddenly there was such a thing as too thin, and it was right in front of me, in the matchstick thinness of her arms and legs, the almost pornographic arches of her ribs, the knobs of her vertebrae.

My feelings about food were turned upside down, too. In the months that followed I became an expert in making calorie-dense concoctions, to deliver the nutrition my daughter needed in the smallest possible footprint. Foods like butter and nuts and ice cream, long banned from my kitchen and my diet, now filled the shelves and freezer and featured prominently at each meal. My husband and I ate what she ate to help her get past her fears about fat, to model for her that this was how normal people ate. I knew I couldn’t show any ambivalence about what we were eating; my daughter is extremely empathic, especially when it comes to my feelings. So I had to not just eat what she was eating, not just pretend it was normal, but actually believe it was. I couldn’t do it for my own sake, but I could do it for her.

Over the next year, as my daughter put on weight and wrestled with recovery, I grappled with my own feelings about food and weight in a new way. My former fear foods were now saving my daughter’s life, and, maybe, protecting my younger daughter from the same disease. Each pound my oldest gained represented not a problem to be solved but a victory over the demon that held her hostage. Now when I saw a young woman who wouldn’t be considered thin, my automatic thought was She’s lucky (though, to be clear, it’s entirely possible to be overweight or obese and suffer from anorexia or other eating disorders). Now when I hit the grocery store, I scrutinized labels looking for the highest-calorie foods rather than the lowest. My daughter and I even laughed about it one night, as we noticed the horrified looks from other shoppers observing our quest for more calories.

But maybe the biggest push to change came from watching other people respond to my daughter. Especially middle-aged women. More than once, when she was sick, they literally approached her in the street to praise her beauty, admire her gaunt figure, even ask her—a fourteen-year-old girl who looked like she was dying—for diet tips. Even friends who knew how ill she was commented admiringly on how gorgeous, how svelte she was. It was as if they couldn’t help themselves. And if I hadn’t seen with my own eyes how much my daughter suffered and how ill she truly was, maybe I would have found her thinness glamorous and beautiful, too.

As she put on weight, those comments dried up. To my eyes she looked infinitely better with every pound; her eyes were shining and she actually smiled. To the rest of the world, apparently, only ribs you could count, sunken cheeks, and a hollow look were worth praise.

I learned a lot from my daughter’s anorexia. I learned about the neurobiology of hunger and appetite, how our “choices” around food and eating are influenced by physiology. People with anorexia nearly always have a family history of eating disorders, anxiety, or both. They also tend toward certain personality traits, inborn characteristics like perfectionism that don’t typically change over the course of a person’s lifetime. I learned that, in fact, both my own struggles with food and my daughter’s illness likely derived from our shared genetics and the way our brains are wired rather than from anything either of us had said or done or experienced.

Most tellingly, I learned how pervasive and deeply entrenched our culture’s preference for thinness has become. We all know this, of course; we’ve read countless magazine stories about it, we’ve taken college courses on it, we talk about it with our friends and families. But until you experience it personally on some level, it’s hard to fathom just how automatic it’s become.

For example: one of my best friends grew up tall and thin, never worrying about her weight. In middle age she gradually put on about 30 pounds. Last year she lost the weight, not because she set out to diet but because she changed the way she ate for health reasons. She was shocked at the number and kind of comments that suddenly came her way. “I began feeling that how I look is of supreme importance to other people,” she told me. “And then it struck me that we shouldn’t be focusing on the physical image we project at all.” She’d been listening to me think and talk about the issue for years, but it took her own experience to make her aware of both how common and how destructive such judgments are. “Honestly, until that moment, the subliminal thoughts I had sometimes about myself and others still had an echo of my mother’s idea that being overweight means ‘having no self-control,’” she said. “Now I don’t think that will be true.”

A HUGE PART of being OK with my body was connected with health. Could I be healthy at this weight and at this point in my life? According to the BMI chart, I was mildly obese, a phrase that haunted me. And of course “everybody knows” you can’t be obese and be healthy.

But what does health actually mean? It’s a fuzzy concept, a word so general, so vague, that it’s virtually meaningless. Is health the simple absence of illness? That didn’t feel right; we talk about health as a positive condition, not just the lack of a negative one. Is health the state of feeling good, energetic, happy? Is it a physical state, or does it include mental and emotional well-being, too?

I couldn’t answer any of these questions. Neither could anyone else, it turned out, though plenty of people have tried, starting with the World Health Organization (WHO), arguably the world’s experts on this subject. In 1948, WHO issued a statement defining health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” That seems more aspirational than realistic; by that standard, I don’t know anyone who would qualify as healthy.

Other experts have tried to refine that definition. Alistair Tulloch, a now-retired British MD, posed the question in a 2005 article in the British Journal of General Practice. He suggested that since we live in a world full of accidents, infections, disease, poverty, poor working conditions, and a host of other adversarial forces, health measures our ability to adapt to and function normally in such a hostile environment. It’s an interesting idea, but it suffers from the same vagueness that afflicts the word health: Who’s to say what “normal” functioning is or what “successful adaptation” looks like?

Around the same time Tulloch was grappling with the concept, Swiss pharmacology professor Johannes Bircher took a stab at the problem with this statement: “Health is a dynamic state of well-being characterized by a physical, mental, and social potential, which satisfies the demands of a life commensurate with age, culture, and personal responsibility.”

That covers a lot of bases; too many, really, like the WHO definition. And it doesn’t bring us closer to a common vocabulary. It doesn’t speak to the fact that what’s healthy for me might not be what’s healthy for you because we have not just different physical and mental needs but different expectations, too. For instance, I’ve struggled with a chronic anxiety disorder since I was ten. Thanks to exercise, meditation, and better living through chemistry, I experience way fewer symptoms than I used to. I function a lot better than I did in my twenties, but maybe not as well as someone without an anxiety disorder. Does that make me mentally unhealthy?

I don’t care either way; I don’t need to slap a label on my mental health. But it does matter to me, you, and everyone when, say, we open a magazine or a website and see the headline “Can you really be fat and healthy?” Because the answer depends on what we mean by “healthy.” Are we talking about medical health? Psychological health? Heart health? Nutritional health?

Medical definitions, which often dominate the conversation, tend to focus on measurable characteristics like cholesterol or glucose levels. Depending on age, gender, genetics, and other factors, one person’s ideal range might be too high or too low for someone else. Even medical health is a constantly moving target, one we’re not likely to come to consensus about any time soon.

But let’s get back to the magazine or the website, to the automatic sense of dread we get when we read a headline that asks whether we can be overweight and healthy. Most of us aren’t parsing the literal definition of health; we’re worrying about our health, our weight. And the message we get over and over is that we can’t be healthy—whatever that means—and also be overweight or obese.

So what do we actually know about the relationship between health and weight? I’ve talked to hundreds of experts, looked at more than a thousand studies, and immersed myself in the research over the last five years to investigate this very question. (And there’s a lot of it; I’ve been told by numerous researchers that the easiest way to get a study funded now is to include the word “obesity” in the proposal. Even better, cite “childhood obesity.”) What I’ve found is that much of what we think we know either isn’t true or doesn’t mean what we think it means, starting with these four often-repeated “facts” about weight and health.

     1. Americans are getting fatter and fatter—at this rate nearly half of us will be obese by 2030!*

We measure overweight and obesity these days using body mass index, or BMI, a ratio of height to weight. Doctors and scientists like BMI because it’s convenient and noninvasive; you just plug in the measurements and voila! You’ve got an easily quantifiable way to characterize, compare, and contrast. The problem with BMI is that it’s not an accurate measurement or predictor of health, especially for people who are shorter or more muscular than average. It doesn’t take into account the amount of muscle or fat in a body, or how strong (i.e., heavy) a person’s bones are. It says nothing about a person’s future risk of disease or death, and it was never intended to. Its creator, Belgian mathematician Adolphe Quetelet, came up with BMI in the 1830s as a way of looking at trends in populations, not in people. But in the late 1970s, researchers began using it precisely as Quetelet hadn’t intended, to categorize individuals’ weight and health status. It’s been the medical model go-to ever since.

Body Mass Index Chart from Vertex42.com. Reprinted with permission.

Using the BMI categories, the most recent reports from the Centers for Disease Control and Prevention (CDC) classify 34 percent of adult Americans as overweight and another 35 percent as obese. About 2 percent of adults are considered underweight; the rest fall into the “normal” category.

The number of overweight and obese Americans* has certainly risen since the mid-twentieth century, with the biggest jump happening between 1980 and 2000. The first researcher to call attention to the change was Katherine Flegal, an epidemiologist at the CDC’s National Center for Health Statistics in Hyattsville, Maryland, which compiles statistics on everything from fertility to mortality. Flegal, who grew up in Berkeley, California, wears her hair short and spiky, and looks at least ten years younger than seventy, has spent her career analyzing all sorts of medical data. According to her research, between 1960 and 1991 the percentage of Americans who were overweight rose from 25 to 33 percent.

It’s hard to get a precise handle on how those numbers compare with today’s, though, because the definitions changed abruptly between then and now. Before 1998, the BMI chart had only three weight categories: “underweight,” or below 18.5 on the chart, which included 2 percent of Americans; “normal,” from 18.5 to 27.3 (the cutoff for men was higher) on the chart, which applied to 40 percent of Americans; and “overweight,” anything above 27.3 (or 27.8 for men), which covered 58 percent of the population. Those cutoffs were revised downward in 1998 to where they are now,, and a category for “obesity” was added. So comparing pre-1998 BMI statistics to post-1998 stats is like comparing pre-steroids home run records to those made in the age of performance-enhancement drugs. In other words, more or less pointless.

Still, we do know a few things. The average American is in fact heavier (by about twenty pounds) and taller (by about an inch) than we were in 1960. And dire predictions notwithstanding, the rates of overweight and obesity leveled off around 2000. We’re not actually getting heavier and heavier; our collective weight has pretty much plateaued.

Why did our weight go up? Plenty of experts have theories, including what I think of as the Big Three: We eat too much. We eat the wrong kinds of foods. We exercise too little. There’s likely some truth in all those statements (for everyone, not just for those on the heavier end of the weight spectrum). But other factors have contributed to the rise as well: Many of us are poorer than we used to be, and poverty is strongly correlated with both how much you weigh and your likelihood of developing certain diseases, like type 2 diabetes.¹ We also live with rising levels of chemical contaminants, and researchers are finding more and clearer correlations between exposure to those contaminants, levels of obesity, and levels of diabetes. The main culprits are the so-called persistent organic pollutants—pesticides, PCBs, and other compounds that build up in our food, water, and bodies²—and endocrine-disrupting chemicals (EDCs) like bisphenol A (also known as BPA). For instance, a 2011 study from researchers at the University of California–Irvine found that early exposure to EDCs, which are found abundantly in plastics, canned food, agricultural fungicides, and elsewhere, made mice fat.³ And a number of studies have confirmed links between the prevalence of diabetes and our exposure to persistent organic pollutants and EDCs.⁴

More of us take psychotropic medications, too: one in five Americans, and more than a quarter of all American women, according to a 2011 report.⁵ Drugs treating anxiety, depression, bipolar disorder, personality disorders, psychoses, and other mental-health conditions are known to cause weight gain, especially when taken over a period of time.⁶ I’ve experienced this myself. The first time I went on an SSRI for anxiety, I gained forty pounds over three years. When I went off the medication, I dropped twenty-five pounds within a month, and the rest soon after. Going back on the drugs was a difficult decision for a lot of reasons, and weight gain was one of them. I remember thinking Which is worse, being fat or being crazy? I chose to take the medication again. This time around I didn’t gain as much, but I still gained some, and I’m guessing that weight will stay with me as long as I take the SSRIs. Which is likely to be for the rest of my life.

Some nutrition experts think the low-fat craze of the 1980s contributed, too. Marion Nestle, a professor of nutrition and food studies at New York University, told Frontline a few years back that the emphasis on cutting fat out of foods led to many Americans eating more carbohydrates, which in turn triggered the weight gain.⁷ (More on that in Chapter 3.) And new research suggests that our long love affair with artificial sweeteners like aspartame, saccharine, and sucralose contributes to weight gain by interfering with the “good” bacteria in our guts, and thus altering our metabolisms.⁸

Whatever the causes, the rise in our average weight has translated to small gains for some and precipitous gains for a few. “About 20 percent of the population is much heavier than it was, but the majority of the population isn’t much heavier,” explains Linda Bacon, a researcher and professor of nutrition at City College of San Francisco. She suspects that the percentage of people who have gained significant amounts of weight are more vulnerable to whatever combination of factors caused the shift in the first place. But we’re certainly not all destined to become obese, says Bacon.

Humans aren’t the only species that’s heavier. Animals are, too. And while human-related changes in diet and activity levels might explain some of that increase, especially among pets and zoo animals, it doesn’t explain the changes for lab animals, for instance, whose diet and activity levels are closely monitored and documented. Their higher weights can’t be blamed on overeating, sedentary lifestyles, or any of the other causes often mentioned in connection with humans. A 2010 study published in the Proceedings of the Royal Society theorizes a different set of factors at work, including, potentially, environmental toxins, viruses, and epigenetic factors we don’t yet understand.

     2. Obesity can take a decade or more off your life.

After charting the prevalence of overweight and obesity, epidemiologist Katherine Flegal began to wonder what her findings meant for Americans’ health. Were more people going to die earlier because they were heavier? To answer that question, she and her colleagues set out to map the relationship between BMI categories and mortality. They expected to find a linear relationship: the higher a person’s BMI, the greater his or her risk of dying prematurely.

But that’s not what they found. Instead, Flegal and her colleagues discovered what statisticians call a U-shaped curve, with the bottom of the curve—the lowest risk of death—falling around 25 to 26 on the BMI chart, making the risk of early death lowest for those now labeled overweight. People considered “mildly obese” had roughly the same risk of dying as those in the “normal” category. Death rates went up for those on either end of the scale—underweight and severely obese—but not by much.

“The differences we’re talking about overall are pretty tiny,” explains Flegal. (Researcher Reubin Andres, who was director of the US National Institute on Aging back in the 1980s, had suggested a similar U-shaped curve, though his was linked more closely with age: the older you are, the less “risky” it is to be heavier.)

As soon as Flegal’s analysis appeared in the Journal of the American Medical Association, the excrement hit the air conditioning. Other researchers claimed her work was shoddy, that she’d left out important data. They said there was no way her results could be accurate. S. Jay Olshansky, a professor of epidemiology at the University of Illinois–Chicago, responded with a journal article arguing that rising obesity rates would shorten lives by two to five years.

That statistic got a lot of attention and helped establish the idea that, as countless media outlets went on to report, for the first time in history a generation of children would have shorter life-spans than their parents. And that prediction is still floating around today, despite the fact that it’s been utterly and thoroughly debunked. As one of Olshansky’s coauthors, University of Alabama–Birmingham biostatistician David B. Allison, sheepishly told a reporter from Scientific American, “These are just back-of-the-envelope plausible scenarios. We never meant for them to be portrayed as precise.”

This type of end-justifies-the-means truth-bending is common in the world of obesity research. Last year, for instance, the National Obesity Forum, an influential lobbying group in the United Kingdom that works on behalf of a long list of pharmaceutical companies, admitted to lying—actually admitted it—in its latest report. The authors had warned that obesity in Britain was continuing to rise, and that an earlier prediction that half the population would be obese by 2050 was “optimistic and could be exceeded by 2050.”⁹ In actuality, rates of obesity in the United Kingdom, as in the United States, have plateaued or diminished slightly. The group knowingly misrepresented the facts “to reach a wider public,” confessed spokesman Tam Fry.¹⁰

Reports like these, which are grounded in opinion and clear agendas rather than fact, feed an increasingly hostile and confusing public conversation around weight. And it’s hard to understand where they’re coming from. I mean, shouldn’t we be glad to hear that a few extra pounds—or more than a few—might not be so bad for you? Might, in fact, even be good for you under certain circumstances?