From The New England Journal of Medicine
The pen is mightier than the sword. In fighting for the health of whole populations, it can also be mightier than the surgeon's scalpel or the physician's medical armamentarium. Sir Edwin Chadwick's Report on the Sanitary Condition of the Labouring Population of Great Britain (1843) hastened the passage of Great Britain's Public Health Act, laying the groundwork for a cleaner water supply. Upton Sinclair's The Jungle (1906) helped to push forward the Pure Food and Drug Act in the United States, ending uncontrolled sales of dangerous medications. Rachel Carson's Silent Spring (1962) laid bare the health risks of pesticides; dichlorodiphenyltrichloroethane (DDT) was banned soon thereafter. Greg Critser's Fat Land attempts to focus attention on a new health crisis: the growing prevalence of obesity and poor physical fitness in the United States. During the past several years, both the popular media and the medical literature have drawn attention to the growing numbers of overweight persons. The prevalence of obesity has risen from 12 percent of adults in 1991 to more than 20 percent in 2001. Obesity rates for adolescents between the ages of 12 and 19 have tripled in the past 25 years, increasing from 5 percent to the current 15 percent. Critser does an excellent job of synthesizing this information, making historical sense of the trends, and citing references for those interested in further reading, and he does so in a fashion that is as pleasurable to read as it is informative. Critser ascribes the rise in obesity to the confluence of several political, social, and economic trends. The early 1970s were a time of peak food prices. President Richard Nixon, fighting an unpopular war in Vietnam and eager to quell dissatisfaction at home, assigned his Secretary of Agriculture, Earl Butz, to the problem. Butz enacted two reforms that had a lasting influence on Americans' girth: he eased regulations on corn production, and he lowered import restrictions on basic staples such as palm oil. The effects of these policy changes were multiplied by new forms of technology. A method was developed to turn the bumper corn crop into a low-cost sweetener: high-fructose corn syrup. Another innovation allowed the transformation of palm oil -- previously referred to as "axle grease" by American importers -- into a palatable substance suitable for use in processed foods. In his reference section, Critser points out that historians have paid very little attention to this area; he should be commended for his good work here. Fast-food marketing efforts also aligned to change the way, and the amount, we eat. As Critser explains, once the staples used to make fast food became cheaper, marketers induced consumers to buy and eat more of them. French-fry vendors in the 1970s noticed that even though consumers "`scrape and pinch around the bottom of the bag for more and eat the salt,'" fear of looking "`piggish'" kept them from buying two bags. Consumer reluctance to go back for seconds was overcome by increasing portion sizes, and "super-sizing" was born. A serving of McDonald's fries "ballooned from 200 calories (1960) . . . to the present 610 calories." Satiety expanded to meet the larger portions. Critser cites research showing that our appetites are not fixed; when presented with more food, we learn to clean our larger plates. Between 1977 and 1995, average daily food intake increased by almost 200 calories. Critser's observations of general cultural trends are less substantiated than his historical arguments, but they are nonetheless interesting. He describes the emergence of a "new boundary-free culture" facilitating the consumption of all these fat-rich, nutrient-poor foods. In earlier times, families sat down for home-cooked dinners, but "the new parent [of the 1980s] had no time for such unpleasantness" and ate out or ordered in. Popular childcare books promoted the theory "that a child `knows' when he or she is full," encouraging parents to cede control over their children's eating habits. Strapped for funds, schools began selling name-brand fast food during lunch. Critser's cultural observations also encompass discussions of religion, the marketing of "easy-fit" clothing, and sports utility vehicles. Most of the material is simplified to support his thesis, but all of it is easy to read, entertaining, and thought-provoking. Overall, Critser's review of science and medicine is good. The relation between poverty and obesity is well documented in the medical literature, and Fat Land gives that association needed attention. In areas where there is less consensus, Critser emphasizes certain studies but admits that more research is needed. For example, he describes changes in the recommendations for exercise over the past 20 years but points to the need for further study. The medical complications of obesity and diabetes are discussed in detail, although diabetic nephropathy, now responsible for approximately 40 percent of incident cases of end-stage renal disease, is not mentioned. Despite his medical omissions, Critser's occasional criticisms of physicians are still compelling. He charges the medical profession with complacency in the face of this growing epidemic, but in doing so he is accusing physicians only of faults they have already pointed out themselves. Most of his arguments come from the Journal of the American Medical Association and other major journals. Reading these critiques in the format of a well-written expose, however, rather than the cooler prose of a medical journal, gives them a more bracing effect. In the last chapter, entitled "What Can Be Done," Fat Land loses a bit of its focus. Rather than offering population-wide solutions to what he sees as a national epidemic, Critser gives anecdotal descriptions of small programs targeted at limited numbers: a modestly successful school intervention designed to combat obesity, an exercise class for "a group of fifteen or so" children with type 2 diabetes, and a pilot program aimed at getting residents of Colorado to walk more. Critser devotes much of his book to describing the way federal policy, crafty marketing techniques, and insidious changes in cultural mores colluded to place Americans, especially poor Americans, in "the first circle of fat hell." It is surprising and a little disappointing that he calls for "individual willpower" -- and the return of gluttony and sloth to their prominent positions among the seven deadly sins -- to "get [us] out of that hell." Commentaries in the medical literature, cited by Critser in his references, suggest more systematic approaches, similar to those promoted in the Surgeon General's campaign for smoking cessation. Fat Land falls short of suggesting an overarching approach to an overarching problem. That is left up to others. Despite these minor shortcomings, Fat Land deserves to be read by all who deal with the medical consequences of obesity and overweight. Jay E. Gladstein, M.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Review
"Urgent and easily digested . . ..Critser lays out the smorgasbord of cultural and economic ingredients that combine to make fatness as American as a deep-fried apple fritter." -- San Diego Union-Tribune -- Review
About the Author
GREG CRITSER is a longtime chronicler of the modern pharmaceutical industry and the politics of medicine. His columns and essays on the subject have appeared in Harpers Magazine, USA Today, the Wall Street Journal, the L.A. Times, and elsewhere. Critser is the author of Fat Land: How Americans Became the Fattest People in the World (Houghton Mifflin), which the American Diabetes Association called the definitive journalistic account of the modern obesity epidemic. He lives in Pasadena, California, with his wife, Antoinette Mongelli.
Excerpt. © Reprinted by permission. All rights reserved.
INTRODUCTION
Obesity is the dominant unmet global health issue, with Western countries
topping the list.
— World Health Organization
Set the soul of thy son aright, and all the rest will be added hereafter!
— Saint John Chrysostom
This book is not a memoir, but it is undeniably grounded in a singular
personal experience. My experience was not, for those hoping for
something juicy, a moment of childhood drama. Nor was it anything that led
to any form of spiritual or true psychological revelation. Compared to the
harrowing tribulations that so much of the world"s population endures, it was,
when all is said and done, rather mundane and petty. Here it is: Some guy
called me fatso. Specifically, he screamed: "Watch it, fatso!"
Here I should note that I deserved the abuse; after all, I had
opened my car door into a busy street without looking into my side mirror
first, and so had nearly decapitated the poor fellow. I could have killed him.
But why . . . fatso? Could it be because I was indeed forty pounds
overweight? Or that I could not fit into any of my clothes, even the ones I
got at the Gap that were labeled "relaxed" (which, come to think of it, I
wasn"t), let alone the ones considered "baggy" (which, again come to think of
it, I was)? Could it be because I had to back up ten feet so as to get my
entire face into the bathroom mirror to shave every morning? Or that when I
dined with friends they hid their small pets and seemed to guard their plates,
one arm curled around them, as if I might plunge my fork into their juicy
pieces of duck and make off with them? I"m obviously joking about the latter,
but the point is that the insult hit home. In upwardly mobile, professional
America, being fat — and having someone actually notice it and say
something about it — is almost as bad as getting caught reading Playboy in
your parents" bedroom when you"re ten. Shame shame shame.
Fatness was hardly a new issue for me. My wife and my
physician had been after me for some time to do something about my
problem, the former quite gingerly, the latter not so. My doctor, in fact, had
recently suggested that I consider a new weight loss medication. At the
time, I had promptly brushed the idea aside. Now, the sting still fresh, I
reconsidered: Why not?
And so, for the next nine months, I put all of my extra energy into
the task of shedding my excess avoirdupois. In modern America, this, I
would find, was a rite in itself, replete with its own social institutions (health
clubs), tonics (Meridia), taboos (Krispy Kreme), and aspirational totems
(Levi"s 501 regular cuts). I was apparently ready for this rite, for, to my
delight, I slowly but surely lost the weight. What followed was encouraging,
if somewhat predictable: congratulations from friends for "sticking to it";
enhanced self-esteem; a new wardrobe; a newfound confidence and spring
in my step; phone calls from J.Lo. and Julia.
Yet the more I contemplated my success, the more I came to see
it not as a triumph of will, but as a triumph of my economic and social
class. The weight loss medication Meridia, for example, had been effective
not because it is such a good drug; even its purveyors freely admit it is far
from effective for most people. What had made the drug work for me was the
upper-middle-class support system that I had brought to it: a good physician
who insisted on seeing me every two weeks, access to a safe park where I
would walk and jog, friends who shared the value of becoming slender,
healthy home-cooked food consumed with my wife, books about health, and
medical journals about the latest nutritional breakthroughs. And money. And
time.
I wrote about these insights, first for a local magazine, then in my
column in USA Today, where I write about the politics of health. I then
moved on to other topics. As is the case with most subject matter, fatness
had remained, at least for me, somewhat abstract, distant — intellectual
rather than emotional. It was certainly nothing one could view as a matter of
national urgency.
Then, two things happened which would change that.
For one, I met a man named James O. Hill. Hill is a physiologist
at the University of Colorado"s Health Sciences Center. Curly-haired, a bit
provocative, Hill is a vigorous, intellectually engaged fellow with an agile
debating style and a wide-ranging presence in his field. Hill"s field is the
study of obesity, everything from its epidemiology to its causes to its
treatment. It was Hill who, only a few years ago, coined what may be the
single most quoted line in regard to today"s soaring obesity rates. "If
obesity is left unchecked," he told the Associated Press, "almost all
Americans will be overweight by 2050." Becoming obese, he went on, "is a
normal response to the American environment." With a presence on all of the
leading public health committees charged with doing something about the
nation"s expanding waistline, Hill is the dean of obesity studies. It was my
fortune to meet him at just the right time.
Hill spelled out the problem more clearly than anyone else. "See,
for decades, most of us believed that the rate of overweight in this country
was relatively static — somewhere around 25 percent of the population
would be always overweight," he recalled one day. "But then, beginning in the
late eighties, we started seeing that rate spike upward, 30, 35, 40 percent.
And that started freaking a lot of us out. Where were the gains coming from?
We know that obesity has a strong genetic component, but twenty years —
anyone knows that is a laughingly small amount of time for genetics to
change so much. So for the guys like myself, the question has become,
basically, what has changed in the environment to allow the inclination
toward overweight and obesity to express itself? What changed around us
to allow us to get so big?"
Big, of course, is putting it mildly. Today Americans are the
fattest people on the face of the earth (save for the inhabitants of a few
South Seas islands). About 61 percent of Americans are overweight —
overweight enough to begin experiencing health problems as a direct result of
that weight. About 20 percent of us are obese — so fat that our lives will
likely be cut short by excess fat. More than 5 million Americans now meet
the definition of morbid obesity; they are so obese that they qualify for a
radical surgical technique known as gastroplasty, wherein the stomach is
surgically altered so as to keep food from being digested. (The American
Bariatric Society, whose members perform gastroplasty, reports that its
waiting lists are months long and that its surgeons "can"t keep up.")
Children are most at risk from obesity. About 25 percent of all
Americans under age nineteen are overweight or obese, a figure that, Hill
points out, has doubled in thirty years. That one figure recently moved U.S.
Surgeon General Dr. David Satcher to declare obesity to be a national
epidemic. "Today," he told a group of federal bureaucrats and health policy
officers, "we see a nation of young people seriously at risk of starting out
obese and dooming themselves to the difficult task of overcoming a tough
illness."
Obesity itself is slowly moving into the middle and upper classes,
but the condition disproportionately plagues the poor and the working poor.
Mexican American women aged 20 to 74, for example, have an obesity rate
about 13 percent higher for those living below the poverty line versus those
above the poverty line. Diabetes occurs at a rate of 16 to 26 percent in both
Hispanic and black Americans aged 45 to 74, compared to 12 percent in
non-Hispanic whites of the same age.
Yet most of America — particularly the America of the Me
Generation — seems to be in deep denial about the class and age aspects
of obesity. Get a group of boomers together and, within minutes, the topic
of obesity shifts not to medical issues but, rather, to aesthetic and gender
issues, to the notion — widely held in the urban upper middle class —
that "talking too much about obesity just ends up making kids have low
self-esteem." Or that it "might lead to anorexia."
Those attitudes also permeate the medical sphere; doctors and
other health care providers remain either in ignorance or outright denial
about the health danger to the poor and the young. In a rare moment of
industry scrutiny a few years ago, the Centers for Disease Control surveyed
twelve thousand obese adults to find out what, exactly, their doctors were
telling them. The results were arresting. Fewer than half reported being
advised to lose weight. A separate study sharpened the indictment: Patients
with incomes above $50,000 were more likely to receive such advice than
were those with incomes below. As the Journal of the American Medical
Association noted, "The lower rates of counseling among respondents with
lower education and income levels . . . are particularly worrisome, because
members of lower socioeconomic groups have poorer health outcomes."
Yes, worrisome. Yet we Americans are inured to such dirges,
which daily seem to well up from the pages of our newspapers. Certainly I
was. Until, that is, the unexpected intruded.
It happened in the Intensive Care Unit of Los Angeles County/USC
Medical Center, one of the nation"s busiest hospitals. I was there visiting an
ailing relative when, suddenly, a gaggle of interns, nurses, and orderlies
pushed a gurney through the ward. On it lay a very large young man,
perhaps 450 pounds, hooked to the ganglia of modern medicine. He had just
undergone an emergency gastroplasty repair, and it did not look good. As I
came to learn, first through bits and pieces exchanged by the ward nurses,
then through comments by the patient"s parents, it was not the first
emergency for this man. As his mother, a modestly dressed woman in her
forties, moaned at one point, "Second time in three months . . . his
stomach keeps coming unstapled" (not all forms of gastroplasty actually
involve stapling, as did older forms of obesity surgery, but many still refer to it
that way). The woman then leaned on the shoulder of her weary
husband. "My . . . boy." Her boy was dying from his own fat.
Yes, he was dying, and yes, the more I looked, the more I could
see: Here was someone"s boy, one plagued, I imagined, by years of bad
health, discomfort, self-loathing, and, of course, countless insults and
snickers by passersby and friends alike. But someone"s little boy
nonetheless. Watching him as he gasped for air — respiratory function is
one of the first things that can go when one gets so big — I could not help
think: There but for the grace of God go I. And, to hear Jim Hill and Dr.
Satcher tell it, a large number of other decent Americans.
Driving home that night, through the barrio of East L.A., then up
the chilly black Pasadena Freeway to the town where I live, I wondered just
how a boy becomes so disabled. Genes certainly played a role, but as Jim
Hill had lucidly pointed out, genes have always played a role in obesity. The
question was, why are we seeing so many more people like the one I just
saw? How — exactly — had they been made? And if it is true that, in
America, every man is his own author, that every man, as Ivan Illich once
wrote, "is responsible for what has been made of him," then what, as a
nation, is being made of us by the obese?
I decided to find out: How is it that we better-off Americans,
perhaps the most health-conscious of any generation in the history of the
world, have come to preside over the deadly fattening of our youth and their
future? That is the story you will read on the following pages, and that is
why we must now turn to the strange career of one Earl L. Butz . . .
Copyright © 2003 by Greg Critser. Reprinted by permission of Houghton
Mifflin Company.
