After the jump, an American-style cornucopia of observations and theories about which Americans are overweight and why. I have been fascinated to read this mail and am trying to share some of the most interesting or representative parts.
First, why med students aren't fat, from a fourth-year med student from Indiana:
"1) From what I've seen, class is a massive factor when it comes to obesity. For us, it's actually frighteningly easy to quantify class when seeing patients -- we rotate through 4 different hospitals here and the term "Wishard Patient" is a well worn code among students/doctors/nurses/etc. Typically, it's used in the context of trauma (gun and knife club) but it's depressing how routine it is to see diabetic patients 50/100/150 lbs overweight in the populations that can least afford care. When working in a clinic for the local indigent population I saw a whole family where I'm certain every member was at least 100 lbs overweight, and a 14 year old girl already weighed over 250 lbs.
2) For some reason, there are very few fat medical students or residents. Undoubtedly some of this is class, but the number of overweight students is too low to be attributed solely to that. This actually kind of surprised me, because I've known my share of fat doctors. My dad was a physician and could have stood to lose 30-40 lbs for most of his life... But I'm constantly amazed at how fit my class is. I can think of maybe 5 people I'd call "overweight" (let alone obese) in a class of 280. I probably work out less than the mean, and I'm 6'2, 200 lbs, lift/run sporadically but play tennis once a week minimum. I have friends who literally look like they can bench press trucks. Some people just never NOT go to the gym, even on their most brutal rotations (sometimes that can mean 100+ hour weeks). That's really inspiring to me.
"But the moral of the story is why that's the case? Undoubtedly some of that is self selection, but I think a lot of it is that the medical hierarchy can be incredibly cruel to the overweight. I suspect it's much harder than an overweight candidate all else being equal to get admitted to medical school to get admitted (maybe even relative to other professional schools or graduate schools). I've seen superiors (staff, residents) just blatantly insult the weight of subordinates -- what comes to mind in particular is a staff physician constantly berating an extremely overweight resident to his face. And honestly, I sometimes wonder how patients would react to an obese physician -- is it tough to tell someone to quit smoking when you're a 100 pounds overweight? I'm not sure."
Are cars the problem, or suburbs? A view from Austria:
"Interesting last post about the perils of car culture. I think it's dead on, but I wanted to emphasize that it's not just cities that come out looking good. The lesson is closer to, it's suburbs that are bad.
"Let me explain. I'm 6-2 and I'm one of those people whose weight varies a lot, it can be as low as 220 or as high as 270. In the last three years I've been dividing my time between rural Austria and suburban Westchester County near NYC. The reason I've been doing this is that my mom is sick in Austria and I have to take care of her and also sell the house in Westchester. So I've been spending stints of 1-2 months in each place for two years now, shuttling back and forth. As your correspondent suggested, when I'm in the suburbs, that's when my weight rises. I drive everywhere, I order takeout food, and so on. The wrinkle is that in Austria, where I'm remote from suburban infrastructure, I rely on my car to an even greater extent, but the lack of distractions means it's much easier to dedicate myself to exercising and maintaining a diet. And my weight drops.
"The good news is, the Westchester house is sold, and when I return to the tri-state area it will be as a resident of NYC without a car. With any luck it'll become easier to maintain a virtuous cycle in both places. "
"My God, you are fat!" From an American reader who goes frequently overseas.
"Whenever I return to the U.S. I have the same slack jawed reaction to the fatness of Americans in general. However, there are several factors at play, as you and others have noted. Statistically, a big part (excuse the pun) of the problem is the definition of "Obese". I am a large man (6'3") and weight, at my peak, 260lbs. Over the last year or so I lost about 55 lbs. I did this primarily because I was tired of my business associates in Asia beginning every conversation with "My god, you are fat!". My own perception was that I was a Clinton-esque, normal middle aged American male. Round at the middle but hardly "obese". That word was reserved for the truly huge among us. Those with gobs of flesh folding over the beltline, winded by a trip up the stairs. The medical community defines "overweight" as having a BMI above 25 and obese as over 30 I currently run 35-40KM per week and swim 1km a day. I still have not gotten my BMI below 25. The data is definitely skewed by this definition.
"Having said all that, our European friends have nothing to scoff at. Plenty of fat people in the UK and the continent. I once had the pleasure of sitting in at a breakfast buffet in Manila watching a chair busting European family wolfing down a breakfast consisting of mounds of scrambled eggs, large stacks of pancakes drenched in syrup. The kicker was between shoveling food into their mouths they sucked down cigarettes. Nothing as impressive as a fat person using one hand to work the food and the other to hold the cigarette."
The problem is the South. Regional food traditions matter. [Original subject line meant as a joke, but it ticked off the reader who sent the message below.]
"It certainly is appropriate to co-relate poverty, class, and educational attainment with obesity. But I suggest that a couple of other cultural factors need to be considered: food traditions and physical activity traditions.
"Food traditions vary by region and ethnic culture in the United States. Physical activity traditions also vary by region and ethnic culture. I have lived in five states in five different regions: Georgia (where I grew up), New York (Ithaca, actually, where I attended Cornell); Colorado; Minnesota; and, now California.
"Southern food traditions rely on fat for flavor and sugar for dessert. Midwestern food traditions rely on meat, often pork, and dairy products. In the Mountain West, the beef culture is significantly modified by an growing emphasis on fresh fruits and vegetables, not to mention a strong culture of physical activity in the form of leisure time exercise and sports. California has a similar food and physical activity culture.
"In the South and the Midwest, the physical activity culture is work-based. As physical labor has declined as a way of making a living in these regions, calories are not worked off, but meal time is still abundant. Southern food traditions include big servings....
"These are all impressions. I do not know if any one has studied and co-related food traditions and physical activity traditions with obesity. Someone should, I think. German food traditions, as one would find in the midwest, might contribute to obesity in the same way as Southern food traditions do."