The headlines in the New York Times and most major magazines had the same message, “It’s Fine To Be Fat”. Being ‘overweight’ (BMI 25-30) is better than being a ‘healthy’ weight with a BMI between 18.5 and 25. The Center for Consumer Freedom, which is a thinly veiled front for the US food and restaurant industry, was ecstatic. The Consumer Freedom group, which is funded by companies such as Coca Cola, Wendy’s and Tyson Foods declared, “The founding fathers greatly enjoyed their food and drink…Now it seems that food liberty—just one of the many important areas of personal choice fought for by the original American patriots—is constantly under attack.” Their message was that all the concern about overweight and obesity stemmed from scare tactics and hype from ‘health Nazis’.

The origin of the ‘fine to be fat’ headlines was an article by Flegal et al. in the Journal of the American Medical Association (April 2005).

Why do the findings of Flegal and her co-authors differ from those of nearly all mainstream scientists and epidemiologists? Firstly, it was a mortality study, which correlated body weight with death. The consensus of opinion is that, although they tried to control for confounding variables that could skew the results, they failed to do so adequately. Without diving into statistical and methodological debates, here are some of the main problems when looking at death and weight.

1. Smoking Smokers tend to be thinner than non-smokers (a major reason given by teenage girls for smoking) but smokers also get cancer and die of cancer. With almost 30% of the US population still smoking there are large numbers of cancerous people with BMI’s between 18.5 and 25 who die. This can show up statistically as a correlation between being thin and dying. An example of how smoking can distort the relationship between body weight and mortality comes from the Nurses’ Health Study, which followed 115,000 US women for 16 years.
   
   All Women (including smokers)
   
   The above graph indicates that there is no significant increase in the risk of dying until after the threshold of obesity.
   
   Compare the above graph to the one that follows, which eliminated the smokers.
   
   Women Who Never Smoked and Had Stable Weight
   
   As soon as the smokers are removed from the cohort, there is an almost linear relationship between risk of dying and body weight, which shows up when BMI reaches 26, well before obesity
   .
   Source: New England Journal of Medicine 333:677, 1995
   
   
2. Aging. How often have you heard people described as ‘old and frail’? Appetite often dies along with the ‘will to live’ and people take to their bed and literally waste away. This ‘will to live’ can be lost at any age, but happens increasingly in later years.
   
   
3. Illness. A number of diseases are associated with unhealthy weight loss, cancer being the most obvious. Unless you can selectively factor out chronic wasting disease you will again see a statistical correlation between low body weight and death.
   
   
4. Medical Advances. We are getting better at keeping fat people alive. We have medications for high blood pressure, hyperlipidemia and diabetes and there are hundreds of surgical procedures ranging from a coronary bypass to knee replacement (which occurs 3 times more often in obese people than those of a healthy weight.)

1. Don’t believe all you read.
   
   
2. Fitness trumps weight.
   At any weight physically fit people are healthier and live longer than sedentary, unfit people. Most fit people are not overweight and most obese people are not fit. However, it’s entirely possible to be fit and overweight, or unfit and normal weight. BMI is an imperfect assessment so that heavily muscled athletic men might be categorized as ‘overweight (e.g. Johnny Duncan, baseball; Kobe Bryant, basketball) whereas some couch potatoes with little muscle mass and significant body fat might slide into a normal weight category.
   
   
3. Obesity is bad, period.
   Leaving aside the overweight/normal weight debate, even Flegal’s statistics show that obesity puts you on a fast track to an earlier death.
   
   
4. Even if it doesn’t kill you, it’s no fun being fat.
   If a judge sentenced someone to wear a 50lb body suit 24 hours a day for the rest of their life, it would be thrown out as cruel and unusual punishment.
   Overweight/obesity put you at much greater risk of the following:

   Type ll diabetes
   High blood pressure
   Stroke
   High cholesterol
   Heart attack
   Congestive heart failure
   Many cancers
   Gallstones
   Dementia
   Osteoarthritis
   Gout
   Sleep apnea

   The old proverb said, “Eat, drink and be merry, for tomorrow you die.” But sometimes you don’t die and are lucky enough to escape with Type ll diabetes, high blood pressure and maybe the odd gallstone. Eat, drink and be wary.
   
   
5. Have fun, eat your fruit and vegetables, go out and play and be careful out there, because nothing’s enough for the person for whom enough is too little.

The Tale of the Tape

One contributing factor to the confusing information in Flegal’s research above may be the use of BMI (Body Mass Index, which is calculated by dividing a person’s weight in kilograms by their height in meters squared), in determining whether someone is ‘overweight’ or ‘obese’. A new study published in the Lancet (November 2005) by S. Yusuf et al. as part of the Global Interheart Study, found that a person’s hip to waist ratio was a much more reliable predictor of a myocardial infarction (heart attack). Yusuf, of McMaster University, found that the waist to hip ratio (WHR) was three times better than BMI in predicting risk of heart attack. In fact, Dr. Yusuf went as far to say that in much of the world BMI is of ‘no value’.

Staying with the words of Dr. Yusuf, “What we know is that fat in the abdomen, which is associated with a larger waist, is metabolically active and produces various hormones that can cause harmful effects associated with diabetes, high blood pressure and hyperlipidemia (high cholesterol). Fat in the abdomen may also relate to fat in the liver.”

A person with a 30-inch waist and 36-inch hips would have a WHR of 83% (anything under 100% is acceptable). To use a fruit analogy this person would be a pear. Whereas a person with a 42-inch waist and 34-inch hips would have a dangerously high WHR of 123%. This is the sort of person who wears elastic waist bands or whose belt is inches below their naval. To stay with fruit, they are described as ‘apples’. (This is the sort of apple that, far from ‘keeping the doctor away’ like the ‘apple a day’, will make it very likely that you’ll be seeing your doctor soon.)

Using more than 27,000 carefully matched people throughout the world it was found that the 20% with the highest HWR were 2.5 times more at risk than the people in the lowest 20%. I’m all in favor of simplicity and HWR seems a lot easier to calculate than any equation that involves height in meters squared.

There are, of course, other simpler ways to assess undesirable weight gain, which include:

  (i) inability to get into your old pants and skirts,
  (ii) if your clothes leave wounds,
  (iii) you can’t wait for the Mu-Mu to be fashionable and
  (iv) the old mirror test. Jump up and down naked in front of a full-length mirror and stop suddenly. If your stomach continues to move, it’s time to eat a little less and move a lot more.

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