Commentators like to opine that we are a “thinness-obsessed society.” They couldn’t be more wrong. A short walk down almost any crowded street in America will reveal the truth: we are a fatness-obsessed society. Americans are fatter than any other major nation in the world, now or at any other time in history.
We are simultaneously repelled and fascinated by the subject of obesity. Not too long ago, the British television program Body Shock showed rescue workers trying to flip over 1,072-lb Patrick Deuel in bed. As he lay there like some freakish-looking giant turtle that had been upended, viewers could see that his underside was flat, like a pancake, having conformed to the shape of the bed on which he had been lying face-down for the past seven years.
What makes people fat? Unless someone has found a way around the First Law of Thermodynamics, the only way to gain weight is to take in more calories than you burn. And the only way to lose weight is to burn more calories than you take in, which means to exercise and eat less. And, as long as there are people who will do anything to lose weight besides exercise and eat less, there will always be a market for weight-loss scams.
Weight loss surgery is big business. In 2006, over 177,000 such operations were performed in the United States alone. A study by the Pennsylvania Health Care Cost Containment Council looked at all bariatric surgeries performed in Pennsylvania in the year 2003 and found that the average cost for surgery and six months of follow-up care was $35, 643. That’s over $40,000 in today’s dollars.
Does the surgery really do anyone any good? Try googling “weight loss surgery side effects” and you will find enough hair-raising and stomach-turning anecdotes to satisfy the most morbid curiosity – click here for a recent example. Here's another. But anecdotes are not data.
Trying to find reliable data on the long-term effects of weight loss surgery is a task akin to trying to flip over Patrick Deuel in his bed. Many of the physicians performing and reviewing these studies are on the payrolls of the medical supply companies. (The medical journals long ago dropped the requirement that authors and reviewers be free of conflicts of interest). Many studies report only short-term outcomes, even though the effects of this surgery last an entire lifetime. Most bariatric surgery patients report dramatic losses for the first year or two, but many end up gaining most or all of that weight back. Some even end up weighing more than they did before the surgery.
I know of only one controlled clinical trial that measured long-term weight loss after bariatric surgery. Odd, given that the whole point of the surgery is weight loss, and the effects of the surgery last a lifetime.
The Swedish Obese Subjects Study assessed both weight loss and mortality in a group of 4,047 obese individuals. Approximately half of these individuals underwent various types of weight loss surgeries, and the other half underwent “conventional treatment” (which, the paper cheerfully explained, sometimes meant “no treatment whatsoever”). Subjects were monitored for an average of 10.9 years apiece after enrolling in the study.
After ten years, subjects in the control group lost essentially no weight. Those who had the lap-band lost an average of 14% of total body weight. That means that someone who weighed 300 pounds before the surgery would end up weighing 258. Someone who weighed 400 pounds would end up weighing 344, etc. Those who underwent the gastric bypass lost an average of 25% of their total body weight. But of course, the side effects of this type of operation tend to be more severe.
Were they any healthier? The study reports that the subjects who had bariatric surgery had a one in one-thousand less chance of dying in any given year after the surgery compared to those in the control group. Over ten years, this comes out to a one percent reduction in absolute risk.
Other studies have reported much more dismal results in terms of mortality. A study published in JAMA evaluated the risk of death for all Medicare patients undergoing bariatric surgery in the years 1997-2002 inclusive. Most of these patients were between 35 and 54 years of age. The one-year mortality rate was 4.6%, or approximately one out of every 22 individuals. There is no other type of elective surgery that has anything like this sort of death toll. All for a surgery which, for the most part, takes obese people and renders them somewhat less obese.
So is weight-loss surgery the solution? If you think about it for a moment, it should be obvious that it couldn’t be. According to this article in JAMA, sixteen million people in this country are considered eligible for weight-loss surgery. At a cost of approximately $40,000 apiece, the bill would come to well over six hundred billion dollars. Assuming a 4.6% rate of mortality for the first year after surgery, that would mean over seven hundred thousand deaths.
Before we go any farther down this road, maybe we ought to step back and take a look at where we are going. We live in a society in which cutting open a woman’s abdominal cavity and rerouting her intestines is considered "normal," and the idea of expecting an individual to exercise a modicum of self-control is considered, well, crazy. What has happened to us?
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Dr. Evan Levine
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Comments
"US" because nothing happened to me on my way to the kitchen.
Sometimes the wheels toward overweightedness get started in the bad direction... then you are left with the aftermath. It sucks all the way around. Also when you see a fat person on the street, think about their personal history, not just "hey if they'd just cut back and exercise a little..." it is not always that easy and you do not know that the person might be in the middle of this search.
If the depression continues, maybe people won't buy so much cheap snack food crap. There's no doubt the huge supply of cheap highly processed stuff they sell has contributed. The stuff does not satisfy, so they want more.
I have cut back on buying stuff that is anything like empty calories. I have lost nine pounds... perhaps that is my silver lining in this recession/thingie.
Look at your data again. Of the control group, basically no one lost any weight by any means whatsoever.
What are the odds that none of those people ever exercised a modicum of self-control?
63% of Americans are overweight. And of those, ALL OF THEM want desperately to lose weight. Fat people face constant discrimination (try buying nice looking clothes as a woman, if you are even slightly pudgy!) and social condemnation. Of that 63% of people, I'm guessing that a couple have heard "Eat less and exercise more."
I agree that before being cut open, I could get pretty damned motivated to lose weight on my own. And I also agree that most of the fat people I have known eat way too much of the wrong kinds of food. The fat person who says, "I eat 1200 calories a day and never lose weight," may be someone who has ruined her metabolism with yo-yo dieting, or someone who has to take steroids which cause her to pack on the pounds - but very often she's someone (and I'm not sure why I'm saying 'she' since the most obese person I know is a man) who is simply lying. But. There's got to be more to it. If 63% of people are failing to do something which they used to be able to do with no problems, that something has gotten harder.
Have you watched the documentary "King Corn"? I saw it recently and one thing that struck me was that American beef now contains 10 times the saturated fat per serving that it used to only 30 years ago. Plus, it's not really meat at all. Grain fed beef isn't beef - it lacks omega-3s which are found in grass fed beef. Take beef to a lab and you can look at it and tell whether it was grass or grain fed because the two are not at all the same thing.
That's just a single example of what I think is a perfect storm of factors besetting Americans today. Government subsidized high fructose corn syrup - in tomato soup. Who needs corn syrup in tomato soup? A "food pyramid" on the back of every package of bread and greasy crackers advising Americans that ELEVEN SERVINGS of white bread a day is good for health, when scientists have discovered that consumption of white bread is more correlated with obesity than any other food. Groceries which push processed foods because those have a high profit margin and downplay natural foods. No restaurant anywhere which serves a salad without a half pound of fatty cheese (again, government subsidized production.) More video games, which absorb people for hours in a way that television doesn't. I make video games for a living and I love 'em, but darn, get up off your ass and see daylight sometimes!
To summarize: I think it's only reasonable to say that Americans have not suddenly suffered a debilitating decrease in willpower. If obesity rates have skyrocketed, the problem has got to be that for some reason, the same amount of willpower isn't enough to keep most people thin.
For most of history, people didn't have to worry about obesity. Our ancestors had to run down wooly mammoths, or spend their livies doing back-breaking labor behind a plow, to get food. Nowadays, getting enough to eat isn't a problem in the developed world. Nowadays, we have opportunities for personal growth that people living in any century before the twentieth could not have dreamed of.
Do we deserve it? Anyone who bloats up to 100 pounds overweight, or 200 pounds, or 300 pounds, and then says to the medical profession, "Hey, I'm not willing to control myself -- just cut me open and put a band around my stomach, or staple it shut and re-route my intestine," is in effect saying No.
People who don't use their freedoms wisely, lose them.
I can't say I agree with the statement, "ALL OF THEM want desperately to lose weight." I think it's perfectly obvious a lot of obese men and women actually take comfort from their supersized bodies. But that's a poor substitute for building character, for developing the internal and external resources to cope with adversity. For others, it may be a way of avoiding their fears of engaging with life.
I am aware that many, perhaps most, severely obese people were abused as children. I will say more about that in a future post.
Gary Taube's book Good Calories, Bad Calories is an excellent summary of the research on various types of diets. Two points that he makes that are relevant to your post are:
1. Research has shown that many obese people can go on near starvation diets and it has very little impact on their weight.
2. The thermodynamic model of dieting that you cite doesn't work as one might expect. What is more important losing weight is the types of food one eats and how those types of foods influence the secretion of insulin in the body. Foods that cause increased secretion of insulin, especially simple carbohydrates, tend to cause increased generation of fat.
The epidemic of obesity that is being experienced world wide is not simply a matter of a loss of self control. It is more likely due to changes in what people eat. If one considers that the incidence of obesity is rising more rapidly among the poor in this country and that simple carbohydrates are a very cheap source of food one can see that there may be a relationship between the two.
I'd like studies that show that near-starvation diets have little impact on how much opbese people weigh. That doesn't make much sense. How long did they stay on these diets?
Having said that, I freely acknowledge that what you eat is important as well as how much. Recently there was a heated debate on OS about the merits of organic versus non-organic produce, a debate I stayed out of. For most people, the most cost-effective change they could make in their diets would be to buy plain old non-organic vegetables and wash the pesticides off. Once you get in the habit of doing that, then you can worry about organic versus non-organic, etc.
Taubes (Good Calories, Bad Calories, 2007) has an excellent summary of the incidence of obesity in poor populations starting on page 240. The major point that Taubes makes is that in groups that perform hard labor on a daily basis and have relatively low calorie intake (less than 2,000 calories a day) there can be high rates of obesity in the adult population and, as one might expect, high rates of malnutrition among the children. Taubes partially attributes this situation to those populations moving to a diet with an extremely high proportion of carbohydrates compared to their traditional diets.
Starting on page 327, Taubes summarizes the results of numerous types of diets, including highly restricted calorie intake diets. The most important finding one takes away from reading this research is that it is the type of diet, carbohydrate restricted vs. fat and protein restricted, that is the most important variable concerning weight loss. With that, Taubes discusses the hypothesis that in situations of starvation, fat tissue may restrict the fat from being burned as a source of metabolism (see page 349). Thus, a person may be very obese, yet starving at the cellular level. Putting an obese person on an extremely calorie restricted diet is likely to make them extremely lethargic, reducing calorie expenditure, without having any effect on weight loss.
One of the most important things that one gets from reading Taubes’ book is that obesity is an extremely complex phenomenon that is mediated by hormones, different types of food, and other factors. Simply asking an obese person to restrict caloric intake may not be an effective strategy for weight loss unless one also considers the composition of the calories the obese person is eating.
Taubes is a well respected science writer. An early summary of his thoughts on obesity and diet can be found in a 2002 New York Times Magazine article: http://www.nytimes.com/2002/07/07/magazine/what-if-it-s-all-been-a-big-fat-lie.html?scp=1&sq=taubes&st=cse .
Mikek, there's plenty of evidence that metabolisms vary. Some people can not metabolize lactose, some can't metabolize alcohol, some people very efficiently recycle b12, allowing a vegan diet with few health consequences. Others rapidly become deficient.
More research needs to be done, but what is right for one person may not be right for another.
To whatever extent obesity surgery works (and, as I mentioned, it s much less effective than people seem to think) it works by making people eat less.
Anyway, I never recommended that anyone go on a starvation diet. What I said was
the only way to lose excess weight was to exercise and eat less. And notice I put exercise first. If someone’s metabolic rate is too low, the only way to increase it is to exercise.
It is perfectly obvious to me that our stomachs evolved to be there size they are for a reason. And it’s also perfectly obvious that we didn’t evolve to be sedentary. I’m sure our Paleolithic ancestors ate heartily, and I am also sure they got plenty of exercise.
I am aware that we live in a society in which slicing open someone’s abdominal cavity and re-routing his digestive tract is considered normal, and expecting people to spend an hour a day walking is considered, well, nuts. I can imagine a society in which those expectations are reversed. That’s why I wrote the essay.
Saying “Obesity is an extremely complex phenomenon” sounds to me an awful lot like throwing up one’s hands and giving up. In the February 24 issue of the Washington Post, there was an article about a fifteen-year-old boy who underwent lap-band surgery. The article mentioned that he eats a double lunch every day. Actually, so did I when I was his age, but guess what? I was on the cross-country team and running eight miles a day and burning it off. They also mentioned that the boy likes to drink a two-liter bottle of soda every day : b That’s eight ounces of sugar, right there. And that’s not even counting the food he eats. That’s before he gets the food. And they said nothing about him taking any kind of exercise at all.
There was nothing wrong with this boy’s stomach. His problem is he doesn’t know how to live, and this operation won’t change that a bit.
To JLee Davis: I won’t apologize for posting those pictures. If you find those pictures shocking, I submit that the problem is that way those individuals are choosing to live their lives is shocking. I am horrified at this vision of ourselves as helpless creatures who can’t help bloating up until we literally can’t stand on our own two feet, and need doctors to perform this expensive and mutilating surgery on us.
To malushinka: I neglected to mention, another problem with the studies on weight-loss surgery is that often there is no control group (as in the one I cited) or else the control group consists of a group of obese patients who have presented to the hospital for various problems, and not a randomly selected group of obese people. The great majority of patients in that study were between thirty-five and fifty-four years of age. I don’t know what the death rate would be in a comparable group of obese people, but it can’t be anything like one in twenty-two.
Again, thanks for your comments.
I have read and reread your words, and I have read all the posted comments, most of which are throught-provoking, and I find it amazing that no one here has mentioned the disease theory. Do you or do you not believe that overeating is in most cases an uncontrollable compulsion (like alcoholism) and that the most visible symptom is obesity? Compare it to alcoholism. If you don't believe it, you don't believe it; go on and keep saying people can control it and would if they wanted to. But please take a minute to examine the long-term abstinence from overeating that exists among groups where overeaters who want freedom from the behavior (as opposed to weight loss). This recovery almost always results in weight loss. Sadly, that's all most "normal" eaters see.