The Washington Post - August 12, 1997

On the beaches, flesh bulges over bathing suits. In the malls, widening waistlines have spawned a booming market for "plus size" clothes. In the schools, kids are fatter and less fit than previous generations.

We are a nation gone to pot-belly.

The cause is not gluttony, said epidemiologist Claude Bouchard at the recent annual meeting of the American College of Sports Medicine in Denver. "We're actually eating a bit less." And it's not fat intake since "our diets are 33 to 34 percent fat now and they used to be 40 percent fat," he added.

Instead, Bouchard, who is a professor at Laval University in Quebec, called "the driving force" behind our growing girth the dramatic decline in physical activity.

"No need to do rocket science to conclude that we are expending less energy than did our grandparents, who had to chop wood and fetch water to survive," he said. Adults expend an estimated 300 to 400 fewer calories per day did than previous generations, he explained, largely because technology has engineered much of the physical activity out of our lives.

That's why public health experts are urging Americans to get off their rear ends. "The best approach to combating obesity is through physical activity," said physician David Satcher, director of the Centers for Disease Control and Prevention in Atlanta, the lead federal agency in preparing last year's U.S. Surgeon General's Report on Physical Activity and Health.

An effort to jump-start a sedentary nation, the report showed that the vast majority of Americans get little or no exercise, and it advocated modest amounts of moderate physical activity to improve health. The advice: Burn 150 calories per day in physical activity such as walking for 30 minutes, stair-climbing for 15 minutes or washing and waxing a car for 45 to 60 minutes.

Exercise isn't about painfully sweating to reach an elusive-and sometimes impossible--cosmetic goal like rock-hard abs or model-thin silhouettes. Instead, exercise is simply spending some time off your behind, doing moderate physical activity that is essential to maintaining good health and preventing disease--including obesity.

Yet in our stressed-out society, many people can't seem to find the time to exercise and instead want a "quick fix." Americans spend more than $33 billion a year on weight-loss pills, potions and paraphernalia, estimates the American Dietetic Association. But these efforts typically fail, and recent studies have suggested that some prescription drug regimens may have serious medical side effects.

In contrast, the most effective weight-loss strategy costs nothing but some time: "Regular exercise is the single best predictor of whether an overweight person will lose weight and keep it off," said Yale University psychology professor Kelly Brownell, who has done extensive research on obesity and eating disorders. Plus, physical activity has other, wide-ranging health benefits including reduced risk of cardiovascular disease, certain cancers, diabetes and osteoporosis.

"If we could get 25 percent of the people who are sedentary up and moving," Satcher said, "we could save $4 billion a year in medical costs."

Satcher and other health officials call obesity "Public Enemy Number Two," right after smoking. It's responsible for 300,000 deaths in the United States each year and is increasing at an alarming rate. These figures from the National Center for Health Statistics highlight the problem:

• The proportion of obese adults has ballooned from 25 percent in 1980 to nearly 35 percent today.
• Women and people in low-income ethnic populations are more likely to be obese, with African American women showing the highest prevalence of all at nearly 50 percent.
• The number of overweight children has increased by almost 50 percent over the last two decades, and the number of "extremely" overweight children has nearly doubled.

If current trends continue, noted Bouchard, "100 percent of adults in the United States will be obese in two centuries."

Healthy Bodies Come in All Sizes

Experts acknowledge that exercise will not make all fat people thin. But it can help them become healthier, since even those who don't lose enough weight to appear slender are still likely to shed enough fat to significantly reduce their risk of disease.

Some people are genetically and physiologically unable to meet societal standards of thinness, note an increasing number of researchers who contend that fit and healthy bodies come in all shapes and sizes. (See sidebar) Some say inactivity itself may be the main cause of disease and obesity merely a marker of the unhealthy lifestyle that leads to medical problems.

New research indicates that obesity is more than merely a problem of eating more calories than we burn.

"There are genetic differences in the susceptibility to weight gain and in the way our bodies build fat deposits," said Bouchard, who with other scientists, is studying the genetic components of obesity in an effort to create a "human obesity gene map" that would identify the genes that put people at greater risk.

Still, environment has a strong impact on obesity, as demonstrated by studies of a native American tribe called the Pima Indians. Most Pimas now live a sedentary lifestyle on a reservation in Arizona where 50 to 60 percent of adults are obese and 60 percent become diabetic. But a small group of Pima Indians moved to rural Mexico generations ago and began a more vigorous, farming lifestyle. These physically active Mexican Pimas have a significantly lower rate of obesity and few cases of diabetes.

"Genes are important," Bouchard said. "But what we do in terms of energy expenditure is also crucial."

Or as Judith Stern, professor of nutrition and internal medicine at the University of California at Davis, put it: "Genetics loads the gun, but environment pulls the trigger.

"For some people it's a hair trigger and for others it's not," Stern said. One indication that genetics is just part of the obesity picture is that "fat people have fat dogs," said Stern, who chaired an Institute of Medicine committee charged with evaluating weight management programs.

"Obesity is. . . a complex, multi-factorial disease of appetite regulation and energy metabolism involving genetics, physiology, biochemistry and the neurosciences, as well as environmental, psychosocial and culture factors," summed up "Weighing the Options," the book Stern's committee wrote to offer guidance in selecting weight-management programs. "Unfortunately, the lay public and health-care providers, as well as insurance companies, often view it simply as a problem of willful misconduct--eating too much and exercising too little."

The grim realities about obesity, Stern said, is that it's "a chronic disease with many causes, including inactivity. We can't cure it, but we can manage it, which means losing some of the weight and keeping it off."

Even Small Weight Losses Help

Typically, weight loss is slow, and regain is common. And treatment, including drugs and exercise, don't work when stopped.

Tens of millions of Americans are struggling to lose weight, often with great expectations based on outrageous claims made by some weight-loss programs. But studies show that those who complete weight-loss programs lose approximately 10 percent of their body weight, only to regain two-thirds of it back within 1 year and almost all of it back within 5 years, according to data compiled in "Weighing the Options."

The best result most obese people can achieve, Stern said, is to lose 15 percent of their body weight and keep it off. For a 200-pound, 5' 4" person, this would mean losing and keeping off 30 pounds, for a maintenance weight of 170. Although this isn't likely to satisfy our culture's cosmetic "thin" ideal, this amount of weight loss can dramatically improve health. Even small weight losses (5- to 10-percent reduction in body fat) are associated with a decrease in cardiovascular risk, improved glucose tolerance, blood pressure and cholesterol profile, reduced symptoms of degenerative joint disease and improved gynecological symptoms.

Yet a person who experiences this great success may still feel like a failure. That's because, at 170 pounds and 5' 4", he or she won't appear thin. Obesity experts have recognized this problem and have changed their approach to focus on health, not thinness.

"Instead of having the goal of weight loss, which is aimed primarily at appearance," Stern said, "the new goal is weight management, which is achieving the best weight possible in context of overall health."

An essential part of this new approach is to focus more on healthy behaviors-exercise and eating right-and to consider how someone feels as opposed to how someone looks. This means changing expectations and recognizing that becoming thin may be impossible for some people.

Becoming healthier, however, is well within virtually anyone's reach. Instead looking to the scale to measure success, individuals look to their ability to maintain healthy habits that allow them to move through their days with energy and ease.

This message hasn't yet reached all physicians, some of whom still shame, blame and alienate the obese. Many primary care doctors still use scale weight as an indicator of body fatness, even though obesity experts prefer using the Body Mass Index, or BMI, a number determined by a formula that uses both height and weight. (See sidebar.) American experts consider a BMI of 27 or more an indication of health-endangering excess weight, Stern said, while Europeans consider a BMI of 25 and above problematic.

While BMI measurements are considered better than the old-fashioned height-weight charts with their so-called "idea" weights, BMIs can be problematic. When people are exceptionally muscular, their BMIs don't accurately reflect their health risk since the number does not factor in how much of the body is fat and how much is lean tissue. For example, Baltimore Orioles' star third baseman Cal Ripkin is 6' 4" and 220 pounds, which gives him a BMI of 27. That puts him in the "moderate to high" health risk category for obesity, even though Ripkin's weight clearly doesn't come from excess body fat.

The most accurate determination of body composition is done by underwater weighing, which requires sophisticated equipment available only in research laboratories. So, for now, obesity experts consider BMI the most practical measure of fatness and associated health risk. Generally, as BMI increases, so does health risk.

No Magic Bullets

Government health goals for the year 2000 call for no more than 20 percent of adults and 15 percent of adolescents to be obese. Yet the nation is moving further away from, rather than closer toward, this goal.

"One remarkable feature of obesity is that its management requires a great deal of effort from the individual," according to Weighing the Options. "And there are few diseases in which health-care providers can offer so little for those who struggle so much."

Surgical treatments can be helpful for some extremely obese individuals, and drug treatments may also be beneficial when combined with healthy eating and exercise habits. "The problem now is the abuse by physicians who are prescribing drugs without lifestyle changes," Stern said. "I'm convinced that until we actually understand more about the disease, we're not going to make any progress until we can get people physically active."

The inactivity trend is particularly disturbing among children, who typically are driven to and from school, lack daily physical education classes and remain indoors and sedentary after school. Not only are the growing numbers of obese children likely to become obese adults, Stern said, but they are subject to numerous psychological stresses such as depression and lowered self-esteem from the discrimination obese people face in our society.

For adults, she pointed to advice from Shape Up America!, a national initiative to promote healthy weight and increased physical activity, chaired by former U.S. Surgeon General C. Everett Koop: Eat sensibly, exercise regularly, drop a few pounds.

"Exercise should be made an honorary vitamin," asserted Koop, who says if he had been able to do one more thing during his tenure as Surgeon General, it would have been to launch a campaign against obesity. "If you don't have it daily, then you're deficient."

---

SIDEBAR: Can You Be Fat and Fit?

In our "thinner is better" culture," most people assume that a slim person is healthier than a chubby one. But this is not necessarily true, note a growing number of health experts who say that fitness level is more important than weight.

"Fit and healthy bodies come in all shapes and sizes," said Dallas epidemiologist Steven N. Blair, who served as senior scientific editor of the U.S. Surgeon General's Report on Physical Activity and Health. An active, heavy person is likely to be fitter than an inactive thin one, said Blair, whose research following more than 25,000 men over nearly 20 years found that fit men had a lower risk of early death than sedentary ones, regardless of weight. It's possible, said Blair, to be fat and fit.

Some health professionals take this controversial position one step further. "Fat itself is not bad for you," contended Glenn A. Gaesser, associate professor of exercise physiology and associate director of the adult fitness program at the University of Virginia. "What's dangerous is the lifestyle" associated with obesity. It's the junk food diet and inactivity itself that's responsible for ill health, not the adipose tissue, Gaesser asserted in his book, "Big Fat Lies" (Fawcett Columbine, 1966). Weight is "meaningless" as an indicator of health and longevity, he said. More important than numbers on the scale are the numbers indicating what he calls "metabolic fitness": blood pressure, cholesterol profile and glucose tolerance.

Becoming "metabolically fit" requires regular exercise.

"I never pitch exercise as a means to lose weight," he noted. "Because most people will not lose a lot of weight." Instead, he urges exercise as a means to improve health, since physical activity can make a dramatic difference in the measures of metabolic fitness even when people lose as few as five pounds.

Obesity isn't a health issue, it's a cultural issue that makes many people miserable because they're unrealistically obsessed with becoming thin, Gaesser said. "Dieting almost always promotes the very thing it is supposed to cure, obesity," he said. "And people often get discouraged about exercise because if it doesn't make them thin, they think they've failed-even if they feel better and improve their health."

Other researchers sharply disagree with Gaesser and warn that it's dangerous to tell people that fat isn't bad. "Obesity is never benign," said Laval University epidemiologist Claude Bouchard. "The environment created by an excess amount of fat alters the metabolism and creates havoc on the health of that person." Some fat is more harmful to health that others, he notes, with abdominal fat being riskier than lower body fat.

Those who say fat isn't harmful "should look at the statistics," he said. Among the strongest: the Harvard Nurses' Health Study of 115,000 women, which indicated that "even mild to moderate overweight is associated with a substantial increase in the risk of premature death."

Yet despite the serious problems associated with obesity, past efforts at trying to get fat people thin haven't worked, said Wayne Miller, professor of exercise science and director of the "Healthy Weight Management" program at the George Washington University Medical Center.

"I tell patients to forget the idea that achieving an ideal body size is the cure all," Miller said. Instead, he advised: "Live a healthy lifestyle, eat right and exercise regularly. Then your weight will settle somewhere that's healthy for you."

Many of the unhealthy habits that lead to excess weight are related to the high level of stress in our lives, said Miller. This is one reason why "most people intellectually know they should eat right and exercise," he said, "but their emotional selves just can't do it."

His approach to obesity is to help patients understand why they behave the way they do, then teach them how to change.

Many unhealthy behaviors--such as smoking, fad diets and eating disorders-stem from societal pressures to be thin, said Pat Lyons, a nurse and health educator from Oakland, Ca. In a culture that glorifies anorexic models and the emaciated look known as heroin chic, she noted, "girls are the fastest growing group of new smokers and many are afraid to quit because they fear gaining weight."

A former chain-smoker and yo-yo dieter, Lyons now calls herself a "fit and healthy fat person" who at 5' 8" with a stable weight of 245-pounds has normal blood pressure, blood sugar and blood cholesterol. The key to her health is regular exercise, said Lyons, a hiker and walker who is at the forefront of a movement advocating physical activity as a way to "become as healthy as you can be, regardless of your size."

All across the country, people are flocking to "oversize exercise" programs with names like Ample Opportunity, Largely Positive and Extrasize, which provide psychologically and physically safe environments for large people who want to exercise. These exercise sessions promote physical activity not for weight loss, but to feel and function better and have fun.

"Instead of trying to get fat people thin," Lyons says, "we're trying to get fat people healthy."

Lyons' studies of participants in her Great Shapes program in California found that regardless of how much weight participants did or didn't lose, 59 percent said that exercise improved their functional fitness: They had fewer aches and pains, more energy, more endurance and a better outlook.

Yet encouraging obese people to exercise for these reasons can be difficult, said Lyons, who is typically asked: "Why bother to exercise if I don't lose weight?"

"This is why self-acceptance and size-acceptance are such critical parts of a new approach to health and weight," Lyons said. "We must focus on helping people see what they have to gain from a more active life, rather than on what they must lose to feel successful."