Critics and experts challenge the goal of thinness as unrealistic and unnecessary; they say fitness is better for health in the long run
By Daniel J. DeNoon
WebMD Weight Loss Clinic - Feature
Reviewed By Michael Smith, MD
Aug. 9, 2004 -- Obesity is a real problem. But the myths we build around it make the problem worse.
The first myth: Fat is bad; thin is good.
The second myth: If you weigh more than "normal," you must lose weight to be healthy.
The third myth: Anyone who is overweight can -- and should -- become thin.
That's the central theme of the new book The Obesity Myth: Why America's Obsession With Weight Is Hazardous to Your Health. Author Paul Campos, JD, is a University of Colorado law professor. He's not a medical doctor -- but he can cite medical literature with the best of them. Perhaps more importantly, he interviewed more than 400 people about their relationship with food, body image, and dieting.
"We are in the grip of a moral panic," Campos tells WebMD. "It is a form of cultural hysteria in which a risk is tremendously exaggerated. Weight has become a dumping ground for neurotic behavior in the culture as a whole. It is this tendency to think in eating-disordered ways that grips American culture."
Focus on Fitness
When we think about "getting in shape," the shape we think about is thin. Being in good shape means improving fitness, but we focus on reducing fatness instead.
Campos points to several major studies often cited as proof that fat kills. A close reading, he says, leads to a different conclusion.
"The crucial variable was not weight but lifestyle changes -- healthy eating and exercise, which seem to be very beneficial whether they produce any weight loss or not," he says. "When people do become more physically active and are cognizant of their nutritional intake, they get real health benefits. Just a little weight loss -- or even no weight loss -- was as good as a lot of weight loss."
CDC data support this idea. CDC epidemiologist Edward W. Gregg, PhD, led a team that analyzed data from some 6,400 overweight and obese adults. They found that people who tried to lose weight -- and did -- live longer than those who don't try to lose weight. That wasn't a surprise.
"What was unexpected was those who tried to lose weight -- but didn't -- those people had a mortality benefit," Gregg tells WebMD. "And our best speculation as to the reason is there are behaviors that go along with weight loss attempts that are good for you. These may have positive effects regardless of whether a person is able to maintain weight loss. They adopt more active lifestyles, they change diets. Over the long haul they are not successful at losing weight, but these lifestyle changes seem to help."
Steven N. Blair, PED, president and CEO of the Cooper Institute, Dallas, is perhaps America's leading advocate for a focus on fitness. He contributed a blurb to Campos' book cover.
"I've never said we should just ignore overweight and obesity," Blair tells WebMD. "But I do think the health hazards of the so-called obesity epidemic are overstated. That diverts attention from a bigger public health problem: declining levels of activity and fitness."
Stanford University's William L. Haskell, PhD, leads a large study of physical fitness, obesity, and heart disease. He's an expert in exercise, health, and healthy aging.
"It is very important that despite being overweight, physical activity has a lot of health benefits," Haskell tells WebMD. "The idea that's out there is if you are not losing weight, you are not getting a benefit from exercise. People think is the case but it really is not."
More Fit Doesn't Mean More Fat
It may actually be healthy for an overweight person to gain some weight -- if the new weight comes as muscle and not fat. Los Angeles psychologist Keith Valone, PhD, PsyD, helps a number of patients in the entertainment industry with issues such as exercise, weight loss, and body image.
"The first thing I do is tell patients to stop focusing on weight loss and to focus on changing their body composition," Valone tells WebMD. "Weight loss really is the wrong goal. The real issue is to reduce percentage of body fat and, parenthetically for most, to increase percentage of muscle mass. Actual weight may increase, but body composition must change. And that comes from changing one's diet and altering one's exercise patterns."
Getting active is only half of the equation. Diet -- as in healthy eating -- is just as important.
"The idea that maybe overweight individuals should focus on activity and not weight loss is probably not a bad idea for a number of people," Haskell says. "But the problem is, we can always eat a lot more calories than we can burn."
Changing to a healthy diet means cutting back on high-fat food and on starchy carbs. It means eating a balanced diet that includes protein, whole grains, vegetables, fruit, fiber, and, yes, some healthy fats. People who do this, and who get moderate exercise, can lose body fat and gain lean muscle.
"The studies suggest that if a 300-pound person drops 30 pounds, that person will have substantial reduction in several risk factors," the CDC's Gregg says. "And also that person will probably see an improvement in physical function and musculoskeletal problems and reduce his or her risk of osteoarthritis. And there would be a whole effect on health-related quality of life that is independent of these risk factors."
America Has an Eating Disorder
People with eating disorders have a distorted body image. They think they are fat even though they are dangerously thin. They are disgusted by fat. They exercise not for health, but to burn away calories. They weigh themselves not to check on their health, but to see how much weight they have lost. They starve themselves on crash diets until their brains rebel, forcing them to binge. The guilt makes them even harder on themselves.
Americans, Campos argues, have a collective eating disorder: We see normal people as fat. We are so disgusted by fat that the only perfectly acceptable prejudice is prejudice against people who are overweight or obese. We go on all kinds of crash diets, then feel guilty for binging on fast food. We are obsessed with weight, to the detriment of our health.
"The emaciated anorexic who looks in the mirror and says, 'I am fat' -- she is just working out the logical consequence of how we have demonized body fat in this culture," Campos says. "It is astonishing what is considered fat in this society."
According to Census data, the average American woman is about 5'4" tall and weighs a little more than 150 pounds. Her body-mass index or BMI -- a measure of weight adjusted for height -- is 26.3, which puts her in the "overweight" category. Yet she's leaner than half the population.
Campos criticizes those who argue that healthy body mass is between 18 and 21.9 BMI -- "for the average woman 5'4" tall, this is between 108 and 127 pounds," he says. "People flinch if you even say the word fat. It is seen as a poison. We see the elimination of fat as desirable. That is eating-disordered thinking. The difference between fashionable thinness and anorexia is whether you have been hospitalized or not."
People come in all shapes and sizes. Yet we think one size should fit all -- and that size is thin.
"We have turned into a disease the fact that there is a huge variation in normal body mass," Campos says. "There is a huge number of people who are physically active and have nothing wrong with them in terms of anything measurable. They are being 'pathologized' because of this ridiculously narrow definition of what health means."
Blair says Cooper Institute studies show people at much higher BMIs than 25 can be quite fit -- although he stresses that extremely obese people, with a BMI of 45 or more, are almost never fit.
"We find that around half of obese individuals -- those with BMI of 30 or more -- about half do well enough on a maximal exercise test to get out of our 'low-fit category,'" Blair says. "Not only is it possible to be fit and fat, a substantial proportion of fat people are fit. I suspect that 15%-20% of normal-weight people are unfit. I'd like to shift the focus away from BMI."
BMI is an excellent tool for epidemiologists looking at weight across a population. For example, BMI quite accurately shows that the heaviest people are at the highest risk of diabetes.
But on an individual basis, it can yield some absurd results. For example, Campos notes, more than half of the players in the National Football League have a BMI of over 30 -- making them "obese." This includes more than three-fourths of the league's linebackers and tight ends. And nearly all of the league's quarterbacks fall into the "overweight" category.
"It is silly for a doctor to just look at someone's BMI number and recommend weight loss," Blair says. "Suppose you have a person with a BMI of 30 or 31, who doesn't smoke, who eats a diet high in fruit and vegetables, who has good [cholesterol] levels, and who runs a mile every day. Do you tell that person to lose weight? Some fanatics would say yes, you've got to get that BMI down. I think that is silly."
Just because it's possible to be heavy and fit doesn't mean that gaining body fat is a good thing. It is not.
"To normalize being fat as healthy and appropriate is not the answer to the problem," Valone says. "To move away from obsessing with thinness to normalizing fatness is substituting one problem for another."
But telling everyone who's overweight or obese that they're bad unless they get thin isn't helpful.
"If shaming fat people about their bodies made people thin, there would be no fat people in America," Campos says. "If dieting made people thin, there would be no fat people in America."
Blair says we should face up to the facts.
"After all, we don't have very effective methods for weight loss," he says. "Let's focus on what people can do -- which is eat a healthy diet and improve fitness. If everybody took three 10-minute walks a day, ate better, and consumed no more than moderate amounts of alcohol, they would be healthier whether they lost weight or not."
Haskell stresses a balanced approach.
"Early on, if an individual has a tough time losing weight, I would suggest they not focus on weight loss but focus on 30 to 40 minutes of moderately intense activity on most days," he says. "If they focus on that, they may see some weight or body composition changes. You may not lose a lot of weight, but you may see a smaller belt size. But you have to eat fewer calories, too."
Take, for example, a man who weighs 220 pounds, consumes 3,000 calories a day, and gets no exercise.
"If that person increased his activity with a good walk every day after work and reduced to 2,500 calories intake, he will produce a 1,000-calorie-a-day negative balance -- that is two pounds a week," Haskell calculates. "He won't lose two pounds every week, but if he does it for 10 weeks he will lose 20 pounds. And that is hard to do by just activity or dieting alone. Doing each moderately can have a sustained effect."
And for heaven's sake, Campos says passionately, let us end what he calls our neurotic obsession with weight loss.
"If you got this nation to stop obsessing about weight, stop dieting, stop paying attention to BMI or these ridiculous definitions, people would be healthier, happier, and weigh less," he says. "Stop chasing this thing you are not going to catch. People say, 'If only I could be the same weight I was when I started dieting. People notice that when they diet they gain weight. The cure is right in front of our faces. ... The way to win is to stop fighting."
SOURCES: The Obesity Myth: Why America's Obsession with Weight Is Hazardous to Your Health. Paul F. Campos, JD, University of Colorado School of Law, Boulder. Steven N. Blair, PED, president and CEO, Cooper Institute, Dallas. Keith Valone, PhD, PsyD, private practice psychologist, Institute of Contemporary Psychoanalysis, Los Angeles. Edward W. Gregg, PhD, epidemiologist, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC. William L Haskell, PhD, active emeritus professor, Stanford University School of Medicine. Calle, E.E. The New England Journal of Medicine, April 24, 2003; vol. 348; pp. 1625-1638. Gregg, E.W. Annals of Internal Medicine, March 4, 2003; vol. 138; pp. 383-389. Fontaine, K.R. The Journal of the American Medical Association, Jan. 8, 2003; vol. 289; pp. 187-193. Allison, D.B. The Journal of the American Medical Association, Oct. 27, 1999; vol. 282; pp. 1530-1538. Dunn, A. L. The Journal of the American Medical Association, Jan. 27, 1999; vol. 281; pp. 327-334. Manson, J.E. The New England Journal of Medicine, Sept. 14, 1995; vol. 333; pp. 677-685.
©1996-2005 WebMD Inc. All rights reserved.