Health May 2010

Beating Obesity

By 2015, four out of 10 Americans may be obese. Until last year, the author was one of them. The way he lost one-third of his weight isn’t for everyone. But unless America stops cheering The Biggest Loser and starts getting serious about preventing obesity, the country risks being overwhelmed by chronic disease and ballooning health costs. Will first lady Michelle Obama’s new plan to fight childhood obesity work, or is it just another false start in the country’s long and so far unsuccessful war against fat?

Moreover, living in neighborhoods among obese people makes one more likely to be obese. Social norms in those areas tend to be more accepting of obesity, so the “social costs associated with being obese,” the authors of a University of Colorado study write, might well be reduced. In 2007, researchers who spent 32 years following the weight of more than 12,000 Americans concluded that obesity was contagious—that people who were close friends with obese people had much higher chances of being obese themselves. Fatness, it seems, is viral.

This jumble of circumstances and effects is what Thomas Frieden means when he says that just being an American can naturally lead you to be obese: obesity is an almost inevitable consequence of living with our cultural norms, our history of agricultural production and subsidies, our long-standing socioeconomic inequalities, and the impact of technology on our behavior and bodies. Against this formidable dynamic, America has erected two lines of defense: name-calling, and hectoring about diet and exercise.

For the average fat person, life can be an endless chain of humiliating experiences. On a flight to Denver not too long ago, I watched as a very large woman struggled to settle into her seat. Next to her, a much skinnier man curled his lip in disgust. The woman softly asked a passing flight attendant for a seat-belt extender. The flight attendant didn’t hear her over the roar of the engines, so the woman had to ask again, and this time, everyone looked at her. Grocery shopping, eating at restaurants, going to the movies, having drinks at a crowded bar—for the fat person, these are situations to be negotiated and survived, not enjoyed. The workplace is no different: a television executive once remarked to me that my career as a political analyst would “really take off if [I] would just lose a few pounds.” When I was fat, I avoided meeting people’s eyes. I didn’t want to subject them to my ugliness.

Unfortunately, our culture reinforces this anxiety by turning obesity into pornography. This is not surprising. Obesity has become not just a scientific fad of sorts, generating intense research, curiosity, and public concern, but also a commercial gold mine that draws on the same kind of audiences that used to go to circus carnivals a century ago to peer at freakishly obese men and women. The TLC network, which long ago transcended its “Learning Channel” origins and gave the world Jon and Kate, now features obesity-programming blocks. One recent special followed the progress of an extremely obese teenage boy who struggled through bariatric surgery and its aftermath. Another special chronicled the life of the fattest man in the world. In addition to The Biggest Loser, NBC’s popular weight-loss boot-camp competition, and Fox’s More to Love, a dating show for larger people, the Oxygen network now has a dancing competition called Dance Your Ass Off. Fat people are funny.

The impact of “fat porn” on fat people is counterproductive. It’s true that stigma can restrain obesity rates. Researchers speculate, for example, that black men are less likely than black women to become obese, in part because within the black community they would face a higher stigma. In general, overweight young people tend to be socially marginalized. But there is little evidence that increasing stigma actually reduces obesity rates. And plenty of evidence shows that stigma makes fat people more likely to feel depressed, to experience stress, to receive poorer medical care, to experience discrimination in the workplace, to go on eating binges, and to duck exercise.

Stigma might be more bearable—an unpleasant way station on the path to a thinner, healthier life—if diet and exercise, the most prescribed solutions to obesity, worked. But they don’t. Qualification: if you eat less and exercise more, you’ll lose weight. But the chances that you’ll stick with that regimen are slim, and the chances that you’ll regain the weight, and then some, are quite high. A systematic review of weight-loss programs, by Thomas A. Wadden and Adam Gilden Tsai of the University of Pennsylvania, found that the evidence that commercial and self-help weight-loss programs work is “suboptimal.” People who diet often regain more weight than they lose.

Much of the solid advice society imparts to people who want to lose weight is best suited, intentionally or not, for well-off Americans. As I was Googling obesity earlier this year, an ad for a book by Jillian Michaels, the take-no-prisoners strength coach on The Biggest Loser, popped up: “Weight-loss expert Jillian Michaels has been there too. After years of exercise and painstaking dieting, she figured there had to be an easier and more effective way to become healthy and stay slim. And there is!”

Later, I flipped through Michaels’s book, and discovered that the real secret is … exercise and painstaking dieting. Michaels’s book argues that our physical environment messes up our hormones, which in turn affect our appetite and energy level. Eat a little of this and some of that, she tells us, but never this and only a smidgen of that. Don’t let stress rule your life. “GO ORGANIC.” “Prepare food to minimize toxins.” You want to know her secrets, but you quickly realize that her day job is her secret; her celebrity status, which lets her see top-flight endocrinologists, is her secret; the freedom her status and position in life give her to follow a diet, that’s her secret. On The Biggest Loser, contestants are plucked out of their environment and social circle, sent to a weight-loss boot camp, and forced to radically change their calorie intake and output for several months. That’s one way to lose weight. But who, besides the very rich, or the very idle, can replicate the show’s setup?

Lest you think I’m advocating the acceptance of obesity, I’m not. As Mark Hoofnagle, a surgeon and a leading crusader against obesity denialism, has put it, just because “modern medicine has largely ameliorated the effects of [being] overweight, that doesn’t mean that being overweight doesn’t put you at risk for a number of problems.” We should care about what we put into our bodies, and we shouldn’t neglect exercise. But we need to recognize the limits of individual agency, especially in the new, “obesogenic” environment that’s been created over the past 30 years, and especially for those in the bottom third of the socioeconomic pyramid. Putting individual solutions and free will up against the increase in portion sizes, massive technological and societal changes, food-company taste-engineering, and the ubiquity of effective television advertisements is like asking Ecuador to conquer China. And yet, that is what public-health campaigns suggest we do.

The government can’t ask someone to pursue a healthier lifestyle—to attain a “normal” BMI, to become a non-stigmatized being—if it isn’t prepared to provide that person with the foundation for health granted to some of us purely by the accident of birth. “Increasing awareness” about healthy lifestyles is not simply gentle paternalism; in the absence of real support, it’s immoral. In that context, stigmatizing young children for being fat is unconscionable; stigmatizing poor adults is only marginally less so; and stigmatizing Mexican American boys and black women and American Indian children of both genders for their weight is both immoral and racist.

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Marc Ambinder is The Atlantic’s politics editor.

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