Book Review: 

“Fat Shame; Stigma and the Fat Body in American Culture” by Amy Edrman Farrell, New York University Press, 2011

This book, by the John and Ann Curley Faculty Chair in Liberal Arts at Dickinson College in Pennsylvania, might have made an important contribution to our understanding the origin and expression of stigma against persons with obesity. Unfortunately, it does not.  It is basically one long membership brochure for the National Association To Advance Fat Acceptance (NAAFA). Nothing wrong with that in itself. But for a college professor I think we could expect a little fact checking and critical thinking. The author lays out her  major points and all are wrong. They are:

1. The  “Obesity Epidemic” is all hype;
2. It is the hype about the obesity epidemic which causes fat stigma;
3. The health effects of obesity are exaggerated or fabricated;
4. The colossal weight loss industry fuels stigma and phony health claims;
5. The commercial interests started stigmatizing persons with obesity in the late 19^th Century;
6. This industry lead  people to futile and dangerous diets and surgery;
7. But there is an  answer in the Healthy-At-Every-Size  program.

#1  The Obesity Epidemic is all hype

Farrell repeatedly puts quotation marks around obesity epidemic, (as in “obesity epidemic”) to indicate her derision  or skepticism for the concept. She writes, “With its connotations of disease, contagion, and proliferation, the choice of the term “epidemic” is deliberately alarmist, suggesting imminent danger and sure catastrophe if not addressed. (At p. 9) Her footnote  instructs us, “Epidemic is a technical term from the field of epidemiology that refers to a disease found at levels higher than expected. In common usage, however, it refers to an infectious disease.”

Comment: Farrell implies by the use of these quotation marks that she doubts the credibility of the obesity epidemic. In fact, the news stories and comments of health experts come from epidemiologists, primarily but not exclusively at the United States Centers for Disease Control and Prevention which reported repeatedly on the epidemic of obesity in the late 1990s onward. See The continuing epidemics of obesity and diabetes i… [JAMA. 2001] – PubMed result and The spread of the obesity epidemic in the United S… [JAMA. 1999] – PubMed result  In fact, searching the National Library of Medicine on-line database, PubMed, one finds nearly 4,000 scientific articles under the search term “obesity epidemic.” So the source of these alarmist views are the very same epidemiologists we rely on for our information about  cancer, HIV/AIDs, smoking, the flu, heart disease.

Her point about “epidemic” commonly being used to refer to infectious diseases misses the point entirely. What the epidemiologists were pointing out by using “epidemic” was exactly this: we were witnessing a unique phenomenon of a non-communicable chronic disease increasing at rates previously only seen in infectious diseases. The then director of CDC, Jeffrey Koplan said in 1999, “Obesity is an epidemic and should be taken as seriously as any infectious disease epidemic.” CDC Media Relations: Obesity epidemic increases dramatically in the United States: CDC director calls for national prevention effort, Released October 26, 1999

Farrell does not directly challenge any of the data about the epidemic only implies disbelief. In fact, the evidence of a sharp, upward spike in the prevalence of obesity in the United States in the later half of the 20^th Century justifies the use of the term epidemic.

Katherine Flegal, the CDC epidemiologist responsible for much of the work on obesity over the past 20 points to ample justification for the use of the term “epidemic.” Commentary: the epidemic of obesity–what’s in a n… [Int J Epidemiol. 2006] – PubMed result.  Kim and Popkin also point out the rise of obesity across the world, including developing countries. Commentary: understanding the epidemiology of over… [Int J Epidemiol. 2006] – PubMed result

#2 It is the hype about the obesity epidemic that is the cause of stigmatization

Lest she wastes any time discussing whether the obesity epidemic is real or not, Farrell quickly moves on to note that similar “troubling, alarming headlines constitute what other scholars, in their work on AIDs and the HIV virus, describe as apocalyptic thinking. Such thinking not only clouds judgment, it also induces a moral panic about the guilt of the one who “causes” such a catastrophe, often leading to extraordinary and discriminatory action on the basis of “health” and “well-being”. This kind of apocalyptic thinking has justified our national “war on fat” which began with Surgeon General C. Everett Koop in the 1990s.” (At p.9)

Comments:  Such thinking only clouds judgment if it is wrong. If you see flames and smoke coming out of your neighbor’s house,  it is not apocalyptic thinking to yell “Fire!” That is what happened with obesity and with HIV/AIDs. Does such thinking induce a moral panic about the guilt of the one causing such a catastrophe? Without doubt, the answer is yes. Is that the whole story? Without doubt no. We witnessed at the outbreak of the HIV/AIDs epidemic a similar kind of moral backlash. Witness the Ryan White story. Ryan White – Wikipedia, the free encyclopedia. As harmful and repulsive as individual stories can be, societies can be educated and change, legal protections can be put in place and societal pressure can change behavior if not attitudes. This is also true on the “war on cancer”.  Cancer used to be heavily stigmatized as well. In both cases of HIV/AIDs and cancer, public responses of research, prevention and treatment included effective campaigns addressing public understanding and combating stigmatization and discrimination.

Like police around a crime boss’s lair, Farrell surrounds health and well-being with those pesky quotation marks. Is she implying that HIV/AIDs does not affect health and well-being or that obesity does not? Or she saying you can only have it one way: ignore the disease and avoid the stigmatization? Would ignoring HIV/AIDs or obesity have avoided cases of stigmatization of gays and lesbians or would ignoring the growth in the prevalence and understanding of  obesity meant that people would not make fun of persons with obesity? Possibly, but I don’t think it so easy.

#3  The health effects of obesity have been exaggerated if not misrepresented .

Farrell again quickly switches to another topic. She writes, “While references to the “obesity epidemic”  are themselves pandemic, not all health experts agree on the physical dangers of fatness.  As Eric Oliver discusses in Fat Politics, it was not until the 1990s that U.S. agencies and medical organizations began to discuss obesity as a “disease,” a designation that legitimated tremendous amount of money spent in research and treatment. Indeed, most reports arguing for the status of “disease,” it turns out, were written – or ghostwritten- by those with a large financial stake in research: pharmaceutical and medical firms that focus on eradicating obesity.” (At p. 11) The footnote here states, “For instance, in 2008, the Obesity Society published a paper defining obesity as a disease. At the end of this paper, the authors acknowledged that “the Obesity Society and members of the writing group have accepted funds from multiple food, pharmaceutical, and other companies with interests in obesity. As investigators for the New York Times noted in 2009, however, many articles in medical journals do not even acknowledge their ghostwriters or financial ties. See Wilson and Singer, Ghostwriting is Called Rife”: Singer and Wilson,” Medical Editors Push for Ghostwriting Crackdown”

Comment: With the exception of a handful of obesity-deniers, I do not know of a single public health expert who does not agree on the physical risks of excess adipose tissue. That is not to say that there is agreement on all possible mechanisms or the conclusiveness of every study. No one familiar with the scientific literature would dispute that. It may be that the contribution of excess adipose tissue to inflammation or to insulin resistance in some groups may be more or less important than total body fat, fat distribution or Body Mass Index. Or that visceral adipose tissue is more important than total body fat.  Searching PubMed for “obesity health effects”, one finds over 18,000 medical articles. While some of these are no doubt inconclusive and some would show no relationship between obesity and a certain risk, others might reveal new risks, like the relationship of morbid obesity to H1N1 virus. But given the volume and wealth of data, the burden is on Farrell to come up with convincing evidence or at least something more impressive than quotation marks.

The issue of the health risks of obesity is different from describing obesity as a disease, however. That categorization as a disease has a number of implications and not all obesity researchers, pharmaceutical companies or other entities much less the public agree obesity should be considered a disease or that the Body Mass Index should define obesity or a particular BMI cutoff should be used. Believe me, I know. I am responsibility for getting most of those U.S. agencies referred to here to recognize obesity as a disease (see Bio),  Also, I have written on this topic and was the second author of the paper referred to in the footnote (and my stuff was not ghostwritten).

Farrell  again misses a good story. She might have observed that Oliver was looking at the activities in the U.S. agencies basically from 1997-2004,roughly my tenure as director of the American Obesity Association. But the Obesity Society paper did not come out for some 8 years later. There was not small concern within the leadership of the Obesity Society at the time that the Society would look a bit foolish coming to this position after so many other groups had done so. The reason is contained in the quoted disclosure statement of the paper which includes some authors receiving funding from food companies who had a lot of concerns about obesity being categorized as a disease.

Second, the designation of a disease did not do a lot to “legitimate” money spent on obesity research. The National Institutes of Health did see a large increase in the late 1990s but this had more to do with the scientific breakthroughs around the discovery of leptin which led to an explosion in the genetic understanding of obesity and, frankly, the lobbying  we did at AOA did for increases at NIH. In terms of treatment, the designation by the Social Security Administration, Internal Revenue Service and Medicare of obesity as a disease were helpful but did not make for sudden or dramatic change in coverage. For example, coverage of drugs for obesity treatment is still uncommon in public or private health insurance programs.

Third, the footnote’s reference to the Wilson and Singer 2009 article in the New York Times deserves some attention. The article had nothing to do with obesity at all. Contrary to the sinister implication of in her text, the Times issued a correction on September 12, 2009 which states, “Because of an editing error, an article on Friday about a study of ghostwritten research reports published in medical journals – reports with unacknowledged research or writing contributions by people other than the authors – misstated the role of drug companies in the reports that were examined. Although other studies have found that journal articles involving ghostwriters are often financed by drug companies, the study in question did not look for or find evidence of drug industry involvement in the ghostwritten articles.”

Now, I have written quite a bit, that obesity is a serious health problem, is an epidemic and should be referred to as a disease…because it meets any rational definition of “disease.” (These quotation marks are mine.) As a point of personal privilege, I have always disclosed any financial interest and the writing, whether at the American Obesity Association, the Obesity Society or this website has been mine. Farrell  ignores any of the facts behind such issues and just strings them along in an implication that everyone else is just on the take.

Farrell goes on to repeat a favorite story of the obesity-denier clan of the CDC having to walk back an estimate of 300,000 deaths a year due to obesity to a more modest figure of 112,000, implying you just can trust those folks.

But what is the evidence on obesity’s effect on health?

Well, it is pretty overwhelming. You can check my section, Health and Stigma, to see just how many health conditions are associated with obesity.  Causation is more elusive. Those connections are  the subject of active research.

First, it is pretty clear that there is a linear relationship of BMI to biomarkers for major diseases, such as C-reactive protein (for inflammation) HbAic (for diabetes) and high density lioporotein cholesterol (for cardiovascular disease).  According to this study, “in all age and sex groups, a higher BMI was associated with a worse biologic risk profile.” Overweight adults may have the lowest mortality–d… [Am J Epidemiol. 2011] – PubMed result .

Many specific connections to obesity-related diseases are very well established, such as:

> hypertension : physiological mechanisms, including leptin, free fatty acids and insulin – whose levels are increased are increased in obesity, act individually and syngergistically to stimulate sympathetic activity and vasoconstriction. Insulin resistance and endothelial dysfunction may amplify the vasoconstrictor response. Pathways from obesity to hypertension: from the pe… [Int J Obes Relat Metab Disord. 2002] – PubMed result and Mechanisms of obesity-induced hypertension. [Hypertens Res. 2010] – PubMed result;

> insulin resistance:  Determinants of incident non-insulin-dependent dia… [Am J Epidemiol. 1993] – PubMed result,  pre-disposing to type 2 diabetes Comorbidities of overweight and obesity: current e… [Med Sci Sports Exerc. 1999] – PubMed result

> type 2 diabetes: BMI is a driver of type 2 diabetes in men and is only modestly attenuated by physical activity. Physical activity, body mass index, and diabetes r… [Am J Med. 2009] – PubMed result

> coronary heart disease:  obesity is an independent risk factor for heart disease Body mass index, waist circumference, and risk of … [Obes Res Clin Pract. 2010] – PubMed result;.

 > colon cancer:  Increased blood glucose and insulin, body size, an… [J Natl Cancer Inst. 1999] – PubMed result 

> pancreatic cancer:  Anthropometric measures, body mass index, and panc… [Arch Intern Med. 2010] – PubMed result  

Overall,  the scientific and medical concerns about obesity have been driven, in my experience, more by the morbidity and disability concerns than by the mortality figures. Controlling obesity is probably more important for controlling for disabilities than for mortality (See Life Expectancy and Life Expectancy With Disabilit… [Obesity (Silver Spring). 2011] – PubMed result and  Mortality and disability: the effect of overweight… [Int J Obes (Lond). 2009] – PubMed result ) In a sample of Medicare beneficiaries, obesity over BMI 35 did affect mortality and, at BMI 30 and more, impacted  functional decline Obesity, race, and risk for death or functional de… [Ann Intern Med. 2011] – PubMed result  This is why one of the very first fights I launched at American Obesity Association was against the Social Security Administration  to keep severe obesity as a condition qualifying for medical disability.

But that is not to say that mortality is unimportant.  A 2009 study of over 20,000 Dutch men and women between 20 and 65 found , in obese respondents,  a four-fold higher risk of a fatal cardiovascular disease (CVD) whereas the risk of a nonfatal CVD was two-fold higher than in normal weight respondents. In persons with a BMI over 25, half of all fatal CVD and a quarter of nonfatal CVD were attributed to their overweight. On the population level, one-third of all fatal CVD cases could be attributed to overweight and obesity and about one in seven of nonfatal CVD cases. Body mass index and waist circumference predict bo… [Eur J Cardiovasc Prev Rehabil. 2009] – PubMed result  A 2006 study of 2,551 enrollees in the Framingham Heart Study who were obese or pre-obese at age 45, found that obesity and pre-obesity were associated with fewer years free of CVD, myocardial infarction and stoke and an increase in the number of years lived with these diseases. 45 year old obese men with no CVD survived 6 years less than their normal weight counterparts, for women the difference was 8.4 years. Interestingly, obese men and women with CVD lived 2.7 and 1.4 fewer years respectively than normal weight individuals. Adult obesity and number of years lived with and w… [Obesity (Silver Spring). 2006] – PubMed result An analysis of the 16,000 persons in US Health and Retirement Survey found smoking contributed to reduced life expectancy while obesity extended disability. Smoking kills, obesity disables: a multistate appr… [Obesity (Silver Spring). 2009] – PubMed result

There are two reasons why some studies of mortality and obesity are inconsistent. The inclusion of smoking and pre-existing disease is one such confounder. The other is grouping the entire range of BMIs in three categories, normal, overweight and obese.

The Prospective Studies Consortium looked at the relationship of BMI to mortality in 57 prospective studies with 894,576 participants in western Europe and North America.  They excluded smokers and those with pre-existing cancer. They found mortality was lowest in the BMI 22.5-25 range. Above that range, they found progressive excess mortality due to vascular disease,and obesity was  probably causal. At a BMI from 30-35, median survival is reduced by 2-4 years; at a BMI of 40-45, it is reduced by 8-10 years, comparable to the effects of smoking. Body-mass index and cause-specific mortality in 90… [Lancet. 2009] – PubMed result. Another study followed which excluded those confounders and looked at 1.46 million white adults with more than 5 years more of follow-up. They found the lowest mortality rate was at BMI of 22.5 to 24.9. Mortality rates increased with progressively higher and lower BMI levels.Body-mass index and mortality among 1.46 million w… [N Engl J Med. 2010] – PubMed result

#4 The colossal  health and diet Industry

Farrell  argues that the attention to the “obesity epidemic,”  “fuels a dangerous and profitable diet industry as well as the growing field of weigh loss surgery.”  And, “Just as Dwight D. Eisenhower in his 1961 Farwell Address called on Americans to be wary of the military-industrial complex, we need, I argue, to be just as wary of the diet-industrial complex…Our national “war on fat” has created  a colossal health and diet industry closely enmeshed with governmental agencies. Profit motives for our sixty billion diet industries and fat stigma have become so entangled that it has become difficult perhaps impossible, to even entertain the possibility that we are fighting the “wrong war”. In a profit-driven, consumer society, diet product manufacturers, pharmaceutical companies, the advertising industry, and medical practitioners all benefit financially from fat stigma. Through their lobbying efforts, these entities influence our governmental offices and agencies and public health campaigns; many in the corporate and medical world also serve as consultants or members of government offices and agencies. Yet, just as the purpose of the military-industrial complex is to maintain itself, not to seek peace, the purpose of the diet-industrial complex is to keep people dieting (or choosing surgery, diet pills, or membership in clubs) rather than to seek health. ” (p.12-14)  

Comments:  All good conspiracy theories need a sinister, behind the scenes  and here we have it – the “weight loss industry. But let’s take a look at some of these claims more analytically.

#1 “Colossal”

The  figure Farrell quotes elsewhere (p.176, for example) on the size of this colossal industry is $60 billion a year, a figure which I believe comes from MarketData, a firm that specializes in economic research on the weight loss industry.  But what is included in that figure?  The categories include diet books, exercise videos,  commercial chains (Weight Watchers, LA Weight Loss, eDiets,  Medifast), diet soft drinks and artificial sweeteners, low-calorie foods (e.g. Healthy Choice, Weight Watchers, Lean Cuisine, Atkins), meal replacements (e.g SlimFast), appetite suppressants (e.g. Herbalife) , medical weight loss  and hospital based programs(e.g. Lindora Medical Clinics, Medi-Weightloss Clinics, Health Management Group), bariatric surgery, diet drugs, fasting programs (e.g Optifast, Health Management Resources) registered dietitians and nutritionists, health clubs (e.g. Bally’s Curves, 24 Hour Fitness), diet food delivery market (Jenny Craig, NutriSystem) and weight loss websites.( Interestingly, dietary supplement business  for weight loss is not included). While the number $60 billion is a big number, I suspect that if one takes out diet sodas, artificial sweeteners, low-calorie foods and meal replacements, which are used by many consumers not necessarily those trying to lose weight or prevent weight gain, the number becomes much smaller.  For comparison purposes, $60 biiion is:

> about 1/3 the size of the fast food industry US Fast Food Industry to Cross US Dollar 170 Billion by 2010

>  1/12 the size of the  $497 billion US food and beverage industry  (give or take a little double-counting) food industry rankings | Top 100 for 2005: This chicken comes first | Food Processing magazine

> about the size of the US battery business Batteries set to become $60 billion industry by ’13 | Green Tech – CNET News.

#2  It is just like the military-industrial complex

What Eisenhower was alluding to was the close financial and personal ties among Congress , the Pentagon and defense contractors. The contractors lobby Congress for new weapon programs, Congress appropriates the money to the Defense Department who gives it to the contractors and personnel move seamlessly between Congress, the Pentagon and contractors. It’s been called the Iron Triangle.  Let me tell you, that is not the situation of the weight loss industry. The weight loss field is highly fragmented. The component sectors do not work together and often define themselves that they are different from the other components. They have no trade association and no source of funding like what Congress is to the defense industry.  When I was director of the American Obesity Association, we were one of the very few organizations that had funding from several sectors, such as commercial programs, the pharmaceutical companies and surgical companies. But it wasn’t easy. And, each sector has different agendas.  The commercial plans, dietary scam artists and dietary supplement folks are scared to death about prosecution by the Federal Trade Commission or the Food and Drug Administration for false or misleading advertising. The pharmaceutical and surgical companies have to go to the Food and Drug Administration for approval but at the same time are competing between and among each other for market share. After approval, they want to be the left alone.  They have mixed views on getting reimbursed in governmental programs. The physicians and medical programs get upset at the government’s often simplistic recommendations to just eat less and exercise more knowing that that is an inadequate solution for most people. When was the last time you heard the Surgeon General recommending bariatric surgery or diet drugs? It isn’t there.

Farrell’s model appears unsuited to accommodate non-for-profit charitable foundations which have become heavily invested in obesity, especially childhood obesity over the last ten years. The most prominent of these is the Robert Wood Johnson Foundation which is not even mentioned. It has committed millions to fighting childhood obesity. Childhood Obesity – RWJF Are they dupes of SlimFast?

Later in the book (p.176), Farrell predicts that the current economic downturn  will only lead desparate overweight persons to add fuel to  the diet industry. This does not seem to be the case according to reports in 2010. It’s The Year of The Value Diet – CNBC. Bariatric surgery rates are also down. Trends in Use of Bariatric Surgery, 2003-2008. [J Am Coll Surg. 2011] – PubMed result

#5  Stigmatization of fat people preceded health concerns

Farrell central thesis is that , “This idea  – that we think poorly of fat simply because we know it is unhealthy – is particularly powerful within our contemporary context when health warnings surrounding fatness are ubiquitous, nonstop and very alarming. What is clear from the historical documents, however, is that the connotations of fatness and of the fat person – lazy, gluttonous, greedy, immoral, uncontrolled, stupid, ugly, lacking in will power, primitive – preceded and then were intertwined with explicit concern about health issues.” (Emphasis added)  (at p.34)

Comment: Unfortunately, the historical record shows exactly the opposite. Health concerns about obesity can be traced to ancient Greeks and Egyptians. Hippocrates wrote about obesity leading to infertility, sleep disturbances, and death. Others, such as Polybus and Galen, also identified health risks associated with obesity. This attention continued through the 16^th and 17^th centuries. In the 18^th Century, the connection between obesity and women’s health began to be made. Obesity: a medical history. [Obes Rev. 2007] – PubMed result

Indeed, the Greco-Roman and Byzantine worlds were quite interested in obesity and saw the best body type as one in which thinness and obesity were in balance. Interestingly, the Mediterranean diet can be traced back to this period. Greco-Roman and Byzantine views on obesity. [Obes Surg. 2007] – PubMed result

Unfortunately, I think Farrell  has missed a major, perhaps the major, cause of stigmatization in America. Its roots, however, are in Europe. This a fusion of Greek philosophy which idealized moderation in all things and the avoidance of extremes and Christianity, which made gluttony and sloth mortal sins (the most serious kind). Gluttony involved both the taking of too much pleasure in eating or drinking as well as overconsumption. The comparable virtues were temperance and diligence.  In the 19^th Century, these sins/virtues would be well known to most American of European-Christian heritage.  The view  can be summarized succinctly as Personal Responsibility.

To this we can add a uniquely  American ingredient – unbridled self-confidence in overcoming our environment and our enemies. After all, we had defeated the world’s greatest military power, Britain – twice. We had survived the Civil War, expanded westward  across a continent, and created unparalled economic growth and opportunities.  We would free ourselves from slavery, build railroads, an interstate highway system, an automobile industry, world-class institutions of education, defeat other empires – Spain, Germany, Japan and Russia, explore space and put a man on the moon. We would defeat numerous diseases and unlock the genome. Through public health measures and medical treatments, we were actually able to extend the lifespan.  Is it a surprise that the first African-American man to beelected President of the United States would share his campaign slogan with that of the National Institutes of Health childhood obesity campaign, We Can?

Whenever issues of obesity have arisen, Personal Responsibility combines with We Can to produce a powerful attitude that if a person really wanted to avoid obesity they have the tools within themselves to do so. Societal intervention, be it in the schools or workplace or community, are not needed, except to repeat the “Personal Responsibility + We Can” mantra.

So stigma is seen, by many I believe, as a good thing because it serves to remind the individual that they are responsible for their health and can fix their problem if they only try hard enough. This is, I believe, a core belief about obesity and persons with obesity.

This view may have some support from a small, recent study which found that people’s views of an obese person as lazy or incompetent were mediated by how they lost weight.  When told the weight loss was due to diet and exercise responders had a more favorable view than when told the loss was due to surgery. Changes in weight bias following weight loss: the … [Int J Obes (Lond). 2011] – PubMed result

Of course, this still begs the question of when stigmatizing people because of their body size started. We may never know this. We do know that by the 16^th Century, Shakespeare was making connections between body dimensions and character. In Julius Caesar, Caesar said of one of the conspirators, Cassius, “ Let me have men about me that are fat, Sleek-headed men and such as sleep a-nights. Yond Cassius has a lean and hungry look, He thinks too much; such men are dangerous.” (Julius Caesar, Act I, Scene 2, l. 190-195) Hostess Quickly of the Boar’s Head Tavern complains of the fat rogue, Sir John Falstaff,  who was depicted as gluttionous, lazy and disloyal, “He hath eaten me out of house and home, he hath put all my substance into that fat belly of his: but I will have some of it out again, or I will ride thee a-nights like the mare.” (Henry The Fourth, Part 2, Act 2, Scene 1, l.74-79)

#6   This industry leads people into futile and  dangerous  weight loss efforts.

Throughout the book, Farrell describes weight loss efforts as either dangerous (like bariatric surgery and yo-yo dieting) or futile or both. The futility of weight loss is a critical element of her narrative. For, if weight loss efforts are successful, then urging people to lose weight is justified. If no one can safely lose weight, it is dangerous and misleading to urge them to do so. She states without citation the old saw that 95% of dieters regain their weight.

Comments:  Farrell sweeps a wide range of interventions into one tent and says all are futile. The reality is far more complex than Farrell presents. The 95% figure has an interesting provenance which I thought everyone in the obesity world knew. It comes from one of the senior scientists in obesity, Dr. Albert Stunkard of the University of Pennsylvania. He described the 95% failure rate in 1959, over 50 years ago. As many people who know “Mickey” as his friends call him, he has regretted it ever since. What he was referring to was the simplistic approach in his clinic at the time of basically telling patients to go home and lose weight. See Book Exclusive: Is Sustained Weight Loss Possible? ;  95% Regain Lost Weight. Or Do They? – New York Times ; Diet and Myths Weight-Loss Lore and Controversies – Why Diets Fail – Term, Obesity, People, Maintenance, Treatment, and Regain  That strategy  wasn’t successful then and it still isn’t. Continual exhortations that this is easy are misleading and can be stigmatizing. But it is not the whole story.

What is failure What is success?

The first question is what is failure and what is success for a diet? This is not an easy question. Many dieters have unrealistic expectations about how much weight loss they can lose. See Weight loss expectations and goals in a population… [Obesity (Silver Spring). 2008] – PubMed result Many feel that losing weight once should be enough to keep it off forever. They are shocked, shocked that the weight loss is not permanent. Alas, it isn’t so.  If one does not take steps to maintain the weight loss, it will come back. But why should we presume that a weight loss should last one year or two or five years or more?

Can people lose weight and does it improve health?

Well, actually yes. In the Diabetes Prevention Program (DPP)  an intensive lifestyle intervention was compared to drug therapy (metformin) to examine a reduction in risk for development of Type 2 diabetes. At one year, intensive lifestyle participants lost 8.6% of initial weight loss compared to controls The lifestyle intervention significantly reduced the incidence of diabetes by 58% compared to 31% in the metformin group, as compared with placebo.  Reduction in the incidence of type 2 diabetes with… [N Engl J Med. 2002] – PubMed result   The 10 year results of the DPP showed significant reduction of type 2 diabetes in the lifestyle group. The group on drug, however, showed less regain than the lifestyle group, indicating that the legacy effects of drug therapy may be understudied. 10-year follow-up of diabetes incidence and weight… [Lancet. 2009] – PubMed result



 A recent study shows that perhaps as many as 20% of participants in lifestyle modification on a low-fat or low-carb diets and behavioral counseling lost about 15 lbs after 2 years Weight and metabolic outcomes after 2 years on a l… [Ann Intern Med. 2010] – PubMed result

Achieving meaningful weight loss in persons with severe obesity without surgery has been extremely difficult. However, in one study of 118 patients, weight loss averaged about 134 lbs. Medications were discontinued in 66% of patients with improvements seen in metabolic indicators. After an average 5 years of follow –up, patients were maintaining an average weight loss of 30 kg. One hundred pound weight losses with an intensive … [Am J Clin Nutr. 2007] – PubMed result Another  randomized trial of persons with severe obesity (BMIs between 35 and 39.9) followed two groups for 12 months. One group had intensive lifestyle intervention consisting of diet and physical activity; the other group had the same dietary intervention but delayed the physical activity component. Both groups lost a significant amount of weight at 12 months, about 26 lbs. Waist circumference, visceral abdominal fat, liver fat content, blood pressure and insulin were reduced in both groups. The addition of physical activity promoted greater reductions in waist circumference and liver fat content. Effects of diet and physical activity intervention… [JAMA. 2010] – PubMed result

So the answer is yes, people can lose weight. It is hard but possible. And yes, it helps mortality. A recent review indicates a mixed picture on mortality for men but clear benefits in mortality for women and diabetics for weight loss. Long-term weight loss effects on all cause mortali… [Obes Rev. 2007] – PubMed result. And morbidity. Relationships between changes in weight and change… [Int J Obes Relat Metab Disord. 2002] – PubMed result  Research has demonstrated its effects on weight related disorders Benefits of sustained moderate weight loss in obes… [Nutr Metab Cardiovasc Dis. 2001] – PubMed result, type 2 diabetes, Lipid and insulin concentrations in obese postmeno… [Am J Clin Nutr. 1992] – PubMed result, and hyperlipidemia, Effects of weight reduction on blood lipids and li… [Am J Clin Nutr. 1992] – PubMed result. Obesity is associated with chronic kidney disease and weight loss advised for its remediation. Obesity and chronic kidney disease. [Nefrologia. 2011] – PubMed result and for improvement of knee osteoarthritis Effects of an intensive weight loss program on kne… [Osteoarthritis Cartilage. 2011] – PubMed result.

Maintenance of Weight Loss

Maintaining weight loss is extremely difficult. There are powerful biological mechanisms which defend a body’s weight.  It has been known at least since 1995 that in obese patients, a 10% decrease in body weight requires a reduction of 15% or more in calorie intake predicted for the same body weight in a normal with person. Changes in energy expenditure resulting from alter… [N Engl J Med. 1995] – PubMed result

But is it the fault of the diet? I have an analogy. You have nice lawn but the grass has grown too high. You mow it. A couple of weeks later, the grass is high again. Is it your lawmower’s fault? Did the lawn care industry make you want to cut the grass? Or is it in the nature of grass to keep growing and need repeated cutting? Does the environment (warm, wet weather) affect the rate of growth? Now, few of us would blame the lawnmower, although blades might be dull. But, by and large, we understand that grass will continue to grow. So it is with weight loss, in my opinion. The diet achieved its loss but the biological properties combined with environmental influences keeps it growing, at least for a while. Weight loss is not a one time thing, unfortunately. A great deal of effort has to go into maintain a lower weight, in large part because of the bodies’s weight maintenance system.

Successful weight  mainteners it seems, engage is some specific activities to maintain the loss. These include a high level of physical activity, low fat diets and careful calorie counting.

Interventions specifically for maintenance may help. In one study, personal contact by a health professional seemed to have better effects on weight maintenance than leaving it just to the individual. Comparison of strategies for sustaining weight los… [JAMA. 2008] – PubMed result 71% of participants remained below their entry weight after 30 months.

In one analysis, weight loss after one year was compared between patients who had surgery and those who lost weight by non-surgical means and participated in the National Weight Control Registry. The researchers found both groups lost approximately 123 lbs after one year with slight regain of about 4 lbs. in both groups. Weight-loss maintenance in successful weight loser… [Int J Obes (Lond). 2009] – PubMed result

Nevertheless, research indicates that the brain perceives weight loss as a deficiency in the hormone leptin and responds with predictable changes in energy expenditure and behaviors related to energy intake. This is a different mechanism than that involved in weight loss, implying that different strategies are needed. Energy intake in weight-reduced humans. [Brain Res. 2010] – PubMed result Weight regain seems to be influenced by higher baseline leptin and lower ghrelin plasma levels, leading to the possibility of predicting who will have better or worse outcomes in terms of weight management. Weight regain after a diet-induced loss is predict… [J Clin Endocrinol Metab. 2010] – PubMed result.

Yo-Yo Dieting

One of the narratives of NAAFA which Farrell uncritically adopts is that repeated dieting is worse than being obese.  The facts do not support her. In a study of 44,882 middle-aged and older women in the Nurse’s Health Study, women who reported they had intentionally lost at least 20 lbs. at least 3 times were classified as severe weight cyclyers. Women who had intentionally lost at least about 10 lbs  at least 3 times but did not meet the criteria for severe weight cyclying were classified as mild weigh cylcers. The researchers looked at all-cause mortalilty and cardiovascular mortality. During 12 years of follow-up, 2,884 women died. Weight cyclers gained more weight than noncyclers but mild cyclers gained about as much as noncyclers. After adjusting for age, weight change, etc, there was no increase in all-cause mortality among mild or severe recyclers. Weight cycling and mortality among middle-aged or … [Arch Intern Med. 2009] – PubMed result The weight regain by severe cyclers may be due to higher levels of binge eating and low levels of physical activity. Association of weight change, weight control pract… [Int J Obes Relat Metab Disord. 2004] – PubMed result Evidence indicates that weight loss and weight fluctuation in men does not increase the risk of death. Weight change, weight fluctuation, and mortality. [Arch Intern Med. 2002 Dec 9-23] – PubMed result

                Surgery

Farrell repeatedly and exclusively describes surgery in only the most negative terms and seems unaware of the significant advances in safety over the last ten years, principally due to the switch from open procedures to laproscopic procedures and the introduction of gastric banding and the move to high-volume centers of excellence.  The considerable body of evidence of the effectiveness  and safety of surgery in appropriate patients, particularly in centers of excellence is addressed elsewhere (See Managing Obesity). To Farrell, any such balanced statements are to be considered “propaganda.” (At p.169)

7         Fortunately, the Healthy-At-Every-Size movement will save the day

Farrell writes approvingly that there is an alternative to the traditional weight loss paradigm , Healthy-At-Every-Size (HAES) which she describes as moving from, “How doe we make fat people thin?” to “How do we make fat people healthy?”  HAES advocates, she says point, to studies that suggest fatness is not particularly malleable, and that restrictive dieting causes only short-term weight loss but results in long-term metabolic disturbances. These advocates, she says,  “argue with studies with headlines that tout the “dangers of obesity” (her quotation marks) usually demonstrate that a sedentary lifestyle and a diet of processed foods result in ill health; and  a diet rich in fruits and vegetables and an active lifestyle will improve health but it may or may not result in weight loss.” (At p. 11) Emphasis in original.

Comments:  First, the traditional weight loss paradigm is not “How do we make fat people thin.” Without doubt, there are a lot of diet products and services which advertise miracle weight loss and the attainment of an ideal body. We call them scams. (See Consumer Protection )They are a deplorable and often deceptive and misleading part of the weight loss world. But they are only a part. Some medical practitioners and surgeons have used  dramatic before-and-after pictures of their most successful patients. But by and large, those practitioners are becoming fewer and fewer, being replaced with younger, more data-driven practitioners.  Enforcement actions of consumer protections laws by the Federal Trade Commission and the Food and Drug Administration have helped drive many of the worst  out of business. Despite these efforts,  they are still around. Their heavy advertising is deeply unfortunate, creating in the minds of many that weight loss is easily attainable without effort.  But most programs today want their patients or customers to have realistic expectations. The medical community and other advocates, such as the STOP Obesity Alliance, have for years urged  a focus on a 5-10% weight loss not for cosmetic purposes but to achieve clinically meaningful health results. Policy Recommendations – STOP Obesity Alliance (Disclosure: I am Policy Advisor to the STOP Obesity Alliance)

Second, we’ve discussed the short term v. long term weight loss above. However, her claim that diets cause “severe long-term metabolic disturbances” requires some explanation on her part.  I think I am familiar with the obesity literature and I have never seen this claim that restrictive dieting causes serious long-term metabolic disturbances. If Professor Farrell has such documentation, she should cite them. (I am assuming this reference does not include gallbladder disease and reduced bone density which could be easily mentioned and are controlled as opposed to the more ominous “serious long-term metabolic disturbances.”)

Third, it may be understandable that Farrell adopts the assumption (driven by stigma in my opinion) that persons with obesity eat a diet high in processed foods and low in fruits and vegetables.  There never was, to my knowledge, any evidence of this. But it is a widely-held assumption. Well,  It isn’t true. According to a recent study, published in 2011, found that energy intake (read calories) increased across all BMI categories – normal weight, overweight and obese groups in 2005-2006 compared to 1971-75. The increases in consumption of carbohydrates (from 44% to 48.7%) and, the decrease in fat consumption  (from 36.6% to 33.7%) and of protein (from 16.5% to 15.7%. Therefore, there is no difference in the foods consumed by persons with obesity and the rest of the US poulation. Trends in carbohydrate, fat, and protein intakes a… [Am J Clin Nutr. 2011] – PubMed result

And what traditional weight loss program does not recommend increased consumption of fruits and vegetables and increased activity? Aren’t these the ones she just said are futile?

So what makes HAES so valuable. HAES espouses three principles, First, don’t try to lose weight. Losing weight is worse health-wise than being obese or overweight. Second, accept your body and don’t try for an idealized body. Third, be active. Fourth, eat intuitively, follow your bodies natural cues as to what and how much to eat. Put the pleasure back in eating. Health at Every Size

Well, there just isn’t any evidence that losing weight is riskier than being obese. No problem with people accepting their bodies and having realistic expectations or being active. However, a good case can be made that we are in the problem we are in regarding overweight and obesity exactly because we have continued to eat intuitively in an unique environment where food is cheap, abundant and safe. Our natural cues have broken down in this environment.

Nevertheless, HAES advocates believe their programs can make persons with obesity healthy without losing weight. HAES’s studies have been around for over a decade and the results have never been impressive. Subjects don’t lose much weight on the HAES program and don’t seem to improve other health parameters. In the most recently published randomized clinical trial, 144 women were randomized to either the HAES group, a support group and a control group. After a year, about 2/3 of the women in the HAES group had a slightly lower body weight at one year. (The mean BMI in this group changed from 30.1 to 29.5 so there was not much change.) But were the subjects healthier, as promised by the HAES advocates. Well, no. The researchers states, “No significant groups by time interaction was observed for anthropometric measures (ie, BMI, and waist and hip circumferences), metabolic parameters (ie, low-density lipoprotein, cholesterol, high-density lipoprotein cholesterol, triglycerides, systolic blood pressure, and diastrolic blood press) and level of physical activity.” Health-At-Every-Size and eating behaviors: 1-year … [J Am Diet Assoc. 2009] – PubMed result

So what to make of HAES? It’s basic premises are simply unsupported by the evidence. It seems less an alternative to medical weight loss programs than perhaps a way to support the much smaller population which is both obese and have disordered eating behaviors. HAES not having much impact. More obese Americans than ever are trying to lose weight by consuming fewer calories, physical activity or both Temporal changes in trying to lose weight and reco… [Prev Med. 2009 Aug-Sep] – PubMed result

The rest and bulk of the book seems like a stream of consciousness exercise stringing along 19^th Century postcards and cartoons, Monica Lewinsky, Oprah Winfrey, Brittany Spears, Barack  and Michelle Obama,  Bill and Hillary Clinton, Al Roker and Kirby Puckett. It is reads like a People magazine of fat stigma.

Fat stigma is a powerful force which has impeded research and treatment of obesity, not to mention justifying terrible treatment of thousands if not millions of individuals. It deserves better exploration than this book provides. Fat shame.