A Matter of Fat
By: Source: AARP Bulletin Today Date Posted: 2005-05-26 08:28:37
For five years Mary Ruth Kelsey has been using a measuring cup instead of a serving spoon, doling out half-cup portions of rice and serving them on a small plate so the tiny amounts don’t look so pitiful. She knows calorie counts and serving sizes. She keeps a food scale on her kitchen counter, and uses it.
"One serving of a boneless, skinless chicken breast is 153 calories," she says. "That’s supposed to be a 3½-ounce chicken breast. I have never seen a 3½-ounce chicken breast. Most are 8 to 10 ounces."
Despite her diligence, the 64-year-old Kelsey, who lives in Pittsburgh, is not slender. She has lost 50 pounds and kept it off for five years, but her weight hovers between 150 and 155. That makes her officially, at 5 feet 3½ inches, overweight by government standards.
Now, after hearing for years that her heaviness is disastrous for her health, and after slowly coming to accept the bitter fact that her weight simply will not fall much lower and stay there, Kelsey is hearing that maybe it is not so terrible to be overweight. Or is it?
National debates over the dangers of fat erupted in April, when statisticians from the Centers for Disease Control and Prevention and the National Cancer Institute reported in the Journal of the American Medical Association that overweight people actually have a lower risk of death than people whose weight is in the normal range. And even the moderately obese are not at much risk, the researchers found—deaths occurred more frequently among the extremely obese and also, to the surprise of many, among the extremely thin.
Very heavy people, those with a body mass index—a ratio of weight to height—that was above 35 (as in a 5-foot-6-inch person weighing more than 217 pounds) had a small increase in their risk of dying, much smaller, for example, than the risk associated with smoking.
The study is widely acknowledged as the most definitive to date. Unlike other studies, it used documented heights and weights, not self-reported statistics, and it was more representative of America as a whole. It came just 13 months after the CDC published a paper warning that obesity and overweight were causing 400,000 deaths a year. The new study attributes 112,000 deaths a year to obesity and extreme obesity but credits overweight with preventing 86,000. That’s a net toll of 26,000.
But the conclusions are controversial. The scientists were asking, What would be an obese person’s risk of dying if weight was reduced to the normal range but no other changes were made? Any existing conditions like diabetes or high blood pressure would remain constant when the scientists calculated the lower risk of death.
They did the same calculation for overweight and underweight people, asking each time how body weight in and of itself contributed to a person’s risk of dying.
That makes sense, many scientists say. After all, the question is not whether diabetes, for example, increases your risk of dying. It is whether a few extra pounds increase your risk. Many people are overweight, or even obese, and have normal blood pressure, normal cholesterol levels, and do not have diabetes. Should they worry that their weight is dangerous?
Some scientists say that, yes, a healthy overweight person should worry, because actual deaths from obesity and overweight are only part of the picture. Excess fat also contributes to health problems—diabetes in particular, and high blood pressure, high cholesterol levels and cancer. An overweight person who is healthy now, they say, is more likely to get sick in the future. It would be folly to tell people to go ahead and eat however much they want, these scientists say.
"Even if we were to accept that mortality rates from obesity are no longer a major concern, we still have to be concerned about the epidemic of obesity," says JoAnn E. Manson, M.D., chief of the Division of Preventive Medicine at Harvard’s Brigham and Women’s Hospital. "Obesity doubles the risk of hypertension and triples the risk of diabetes. There is an enormous burden of disease, and it impairs the quality of life."
Madelyn Fernstrom, director of the University of Pittsburgh Medical Center’s weight management center, not only believes the new data but welcomes the new findings. Too many people, she thinks, have been discouraged from the sort of weight control that can increase their energy and improve their well-being by the insistence that they are successful only if they achieve a "normal" weight range.
"One of the single biggest deterrents to the public trying to lose weight is that it’s never enough, so forget it," she says.
Even for people who want to control their weight, it can be hard to learn new eating habits. And the new food pyramid from the U.S. Department of Agriculture is of little help, Fernstrom says, because it is too confusing and laborious to use. To make matters worse, there are now competing pyramids—the Mediterranean Diet pyramid, the Harvard School of Public Health’s Healthy Eating pyramid, the University of Michigan Integrative Medicine’s Healing Foods pyramid, the diabetes pyramid. No wonder people throw up their hands in dismay, Fernstrom says.
Yet her patients, like Mary Ruth Kelsey, who have learned to carefully monitor their eating and have come to terms with a more modest weight loss say that losing weight has transformed their lives. With weight loss, Kelsey discovered exercise and the pleasure of easy movement.
"I’m not kidding when I say that it was a problem for me to tie my shoes," she says. "I could do it, but it was uncomfortable. People don’t realize how much their lives are compromised by having a big stomach. And my energy level is amazingly different."
She looked at the Department of Agriculture’s new food pyramid to see if it could help her continuing efforts to monitor what she eats. "It’s just bizarre," Kelsey says, too complicated. And, she adds, people who really need guidance are even less likely to understand the pyramid. "Everyone in my family is obese except for me," Kelsey says. "Not one of them would ever look at that food pyramid in a million years."
Others in Fernstrom’s weight management program, like 50-year-old Pam Holland, say a moderate weight loss—30 pounds in her case—makes everyday life easier. "My clothes fit. I’m bending over and crossing my legs," she says. At 5 feet 3 inches and 156 pounds, Holland knows she is overweight and that people judge her for it. But she has struggled her whole life to lose weight—she was put on diet pills at age 8 in her first vain attempt to get thin—and if she could be slender, she would be.
"We beat ourselves up" for not being thin, Holland says. But the new study and her own experience tell her "it’s okay, finally."
Research repeatedly confirms Holland’s experience that it is not easy to lose weight. Although usually prone, like most commercial programs, to dismissing the issue of effectiveness through fine-print disclaimers, Weight Watchers did in 2003 assess its success by studying 423 people averaging 205 pounds. Half were assigned to Weight Watchers. Two years later, they had lost an average 6.4 pounds. The other half were assigned to lose weight on their own. They lost nothing.
As for research studies, in which subjects typically are lavished with support and education and attention, the long-term results are not encouraging, says Thomas A. Wadden, director of the weight and eating disorders program at the University of Pennsylvania. "There is pretty good evidence that people can lose 10 to 15 percent of their weight and can sustain it," he says. "But I’m not sure most people can sustain a weight loss of 20 to 25 percent."
That would mean that someone like Holland, who went from 186 to 156 pounds, a weight loss of 16 percent, was just about at the limit of what is feasible for most people.
And that sort of moderate weight loss is the most that should be expected, according to Barry Glassner, professor of sociology at the University of Southern California. "There is this huge assumption that if people just work at it, they can lose weight," he says. "In fact, a huge body of literature contradicts that."
But scientists also find that being overweight does not have to mean being unhealthy.
Steven N. Blair, president and CEO of the Cooper Institute in Dallas, said his studies following thousands of subjects for years have long shown that being fit is more important than being thin. In fact, overweight people may have advantages. They have a lower risk of death than people of normal weight, says David Williamson, an epidemiologist at the CDC. Scientists have long puzzled over what they called the obesity paradox: For unknown reasons, when people reach their 70s and 80s, those who are fat fare better when they are ill than those who are thin, even doing better in surgery.
Still, some who are struggling with obesity say that, death risk aside, they know they would feel better if they could lose some weight.
That is the case with 70-year-old Ed Goldston. He has been a patient at Fernstrom’s weight management program for years, but he weighs 302 pounds, "exactly 50 pounds below when I started but 59 pounds more than my low point," he says.
He has always been fat and knows he will never be thin. But he is still trying—after all, he felt better when his weight was lower. "I’m having a harder time getting around, and my arthritis is kicking in," he says.
And no, the new study did not make him feel entitled to eat what he wants, Goldston adds. But if it turns out that being obese is not quite as great a death risk as scientists had thought, that would be fine with him.
Gina Kolata is a science and medical reporter at the New York Times.
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