The following is an abridged version of my letter to Dan Savage. Rather than engage in a “I hate you/you hate me” pissing match, I am responding only to the inaccurate factual information contained in Dan’s response to Lindy West. This is one of the most exhaustively cited posts I’ve written on the subject of obesity and health, so if you want to understand the subject further, please read the full post.
I’m not a regular reader of your column (I’m really not a regular reader of anything), but I appreciate what you do in the form of activism, such as ushering in a more open and honest dialogue about our sexuality and the whole “It Gets Better” campaign. I appreciate your honesty and openness, but I think your attempt to confront obesity head-on is counterproductive on many different levels.
There seems to be a pissing match going on between Savage and the Fatties that is more about who can take the other down a notch than actually having the sort of dialogue that I would imagine you would typically encourage on such an important and controversial issue. So, here’s what I propose: a cease fire. An end to hostilities so we can actually talk about the important underlying issues, instead of resorting to homophobic and fatphobic slurs.
As much as I’m a fan of the well-executed, surgeon’s slice of sarcasm, I’m going to hold off on any negativity for now in order to lay out where I believe you may not be relying on the most accurate or reliable information, or your interpretation may be lacking a more comprehensive understanding of the issues.
A perfect example is when you say:
I will continue to post the links to stories about the obesity epidemic that catch my eye, stories like this that give the lie to the whole lack-of-exercise-has-nothing-to-do-with-it crap pushed by fat-acceptance crowd.
The story explains how Mississippi has the highest rates of obesity and sedentary behavior, while Colorado is the only state with an obesity rate less than 20% and is the third most active state. The author says that “it’s not likely a coincidence,” but it is a gross over-simplification to conclude that a lack of physical fitness is the only, or even the main, cause of obesity in Mississippi or leanness in Colorado.
For example, according to source for this article, the “F as in Fat” report (PDF), Mississippi has the highest rate of physical inactivity (32.2%) and obesity (33.8%) and Colorado has the lowest obesity rate (18.0%) and ranks 49th in physical inactivity (19.1%). They fits neatly into your theory. But then how do you explain Minnesota, which has the lowest rates of inactivity (16.9%), yet ranks 32nd in obesity (25.5%)? Or New Jersey that ranks 42nd in obesity rates (23.9%), but is the 11th most inactive state (26.4%)? Or New York at 36th in obesity (25.1%) and 14th in inactivity (25.7%)?
In fact, the chart reveals that although there is some overlapping of the two categories, it is hardly what you would call a strong correlation (click the thumbnail below for the full chart):
But if you want to play the correlation game, I’ve got an even better one for you. Below is a map of states with the highest rates of people living below the poverty line from the US Census report titled “Poverty: 2008 and 2009″ (PDF):
Among the 16 states with the highest percentages of people living below the poverty line are all 11 of the fattest states (Mississippi, Alabama, Tennessee, West Virginia, Louisiana, Oklahoma, Kentucky, Arkansas, South Carolina, North Carolina and Michigan). Coincidentally, Mississippi ranks the highest (21.9%), with the second closest being Arkansas (18.8%).
But more importantly, you and others frequently cite Colorado as a beacon of fitness and self-control, the last hope for our nation. You are among the multitudes crying, “What is Colorado doing right?“, “Why are Coloradans skinnier than everyone else?“, “Hey, let’s all be like Colorado!“
Of course, what is left out of this discussion entirely is the fact that Colorado’s obesity rates rose faster than any other state, and another recent study says the same trend applies to childhood obesity in Colorado. So Colorado is the thinnest state, but they are getting fatter faster than any other state. Is that really proving your “exercise cures obesity” theory, Dan?
It is true that for those patients who begin a permanent lifestyle change, there is a possibility of losing weight, but the average sustainable weight loss is 5-10% of your original body weight. Let’s say you see a morbidly obese person walking down the street: she’s 5’7″, 300 pounds.
You might look at her and think, “She should eat better, exercise, and not rely on fad diets, then she’d lose the weight.” This approach is best exemplified in the Learn Program for Weight Management by Dr. Kelly Brownell, Director of the Rudd Center for Food Policy and Obesity at Yale. Learn is the most commonly prescribed weight loss program and is also known as the slow and steady approach.
But Learn has its limits, according to this one-year randomized controlled trial of commercial internet weight loss programs. Participants either used eDiets or the Learn manual. Learn did better than eDiets, but only induced a 4% total body weight loss after a year and an average weight loss of 7.27 pounds (plus or minus 9 pounds). As you can tell by this table, the major weight loss was immediate, then tapers off. And I can’t find many long-term trials (which is pretty common among weight loss research).
So, that 300 pound woman could have already shed 10% of her original 333 pound body weight, but you wouldn’t know it. And according to Dr. Sharma:
The good news is for many obesity-related health conditions a 5% or 10% weight loss can have very remarkable effects.
Which brings me to my favorite interview of all time: Dr. Steven Blair, Professor at University of South Caroline Department of Exercise Science, specializing in the Division of Health Aspects of Physical Activity. He’s also one of the most widely cited fitness researchers in the field and is best known for his work ground-breaking at the Cooper Institute.
Dr. Blair concurs with Dr. Sharma’s comment that you can’t judge a fatty by his belly:
You can’t tell by looking if someone is fit or not. In fact, in our research if we look at adult men and women body mass index of 30 or greater, about half of them are fit by the cardiorespiratory fitness standards that we’ve used in our research and health outcomes.
A person in the Obese BMI category who engages in regular, physical activity (the minimum 150 minutes of moderate exercise or 75 minutes of intense exercise per week), are as healthy as physically active people in the other BMI categories:
Our research has focused on what your fitness level actually is and we see the benefits of having at least moderate cardiorespiratory fitness being relatively comparable in people who are normal weight or overweight or obese.
Dr. Blair has also found that BMI or weight is not the strongest indicator of health by a long shot:
Bottom line, what we’ve found, is that low cardio-respiratory fitness, those who are unfit, is really one of the strongest predictors of morbidity and mortality of anything we’ve measured in this data set. For example, 16 to 17 percent of the deaths… over 50,000 men and women followed for on average more than 10 years and about 4,000 of them died. 16 to 17% of those deaths can be said to be caused by low fitness. 2 or 3% of the deaths were caused by obesity. I think that 4 or 5 or 6% to diabetes. The only thing that was even close to low fitness in terms of the number of deaths it caused in the population was hypertension in men.
Hopefully, this information gives you a good foundation for understanding why health and obesity are not inextricably linked as the media leads us to believe. But you’re probably still concerned that obesity rates are rising and our nation will soon be awash in flabby rolls of excess flesh. Hell, just turn on the TV and you’ll hear all about how fat we’re getting every day.
Except, that’s not true either.
Obesity rates have leveled off:
The increases in the prevalence of obesity previously observed do not appear to be continuing at the same rate over the past 10 years, particularly for women and possibly for men.
In fact, the obesity rates for women and children have been stable since 1999 and for men since 2003. The author of that study is Dr. Katherine Flegal, Senior Research Scientist and Distinguished Consultant of the CDC’s National Center for Health Statistics.
She’s the one who completely debunked the CDC’s initial estimate of 400,000 annual deaths in the obese AND overweight ranges. Turns out, the obese AND overweight category are actually responsible for 26,000 annual deaths, but that’s due to the fact that the overweight category has a negative mortality (meaning they live longer than expected) of 86,000, while obesity is associated with 112,000 annual deaths. The CDC now accepts Flegal’s estimate as the most accurate.
When you compared the mortality of obesity to smoking, you are basing it on the old CDC estimate of 400,000, but even if you cite the 112,000 number for obesity alone, that still makes the mortality rate of obesity (4.6% of total deaths) much closer to the death rate of alcohol use (3.5%) than smoking (18.1%).
And if you break down the numbers, you’ll find that although 112,000 people die due to obesity each year, there are approximately 105 million obese Americans in all (34% of the population is obese). That means the annual risk of death due to obesity is one in 937 or 0.11%. That is not an astonishing risk.
But judging by your comments in this post, you would think fatties were dropping like flies:
It’s an article of faith that we can’t talk about how much crap we’re eating–or how awful we look in low-rise jeans–without inducing eating disorders in millions of silly and suggestible young women … Our obsession with anorexia, Critser goes on, not only covers up America’s true eating disorder (we eat too much and we’re too fat!), but it also hamstrings efforts to combat obesity, a condition that kills almost as many people every year as smoking does. Eating disorders, by way of comparison, lead to only a handful of deaths every year. If you’re truly concerned about the health and well-being of young women, THUD, worry more about the skyrocketing rates of obesity-related diseases in young people–like type 2 diabetes–and less about the imaginary link between anorexia and my low opinion of low-rise jeans.
Which brings me to my second grievance about your handling of the issue of eating disorders. You seem to be one of the people who says, “Hey, anorexia isn’t a big deal. It doesn’t kill that many people. Let’s focus on the fatties!”
Now, there are all kinds of estimates as to how much obesity affects your Years of Life Lost (YLL), but while doing some research on lap-bands in adolescents, the most commonly cited figure is 8 years. So, an obese teenager can have a life expectancy of 70 years versus the standard 78, which is tragic, but not exactly terrifying.
Compare that with adolescent alcohol consumption, which conservative estimates suggest shave 10-12 years off your life. But drinking in teens is to be expected, right? Besides, they’ll have plenty of time to turn themselves around and improve their health later on.
Yet you easily dismiss eating disorders because they lead to only “a handful of deaths” each year.
It disappoints me immensely, Dan, that you would be seen as dismissing eating disorders as a life-threatening problem among (especially) teenage girls. I’ve written about this subject at length, but I’m happy to provide you the salient data here because once again, your facts are skewed:
Females between the ages of 15 and 24 are 12 times more likely to die from anorexia than all other causes of death, according to the National Eating Disorders Association in America.
Anorexia is the deadliest mental illness among teenage girls, but it’s “just a handful,” right? So let’s take a look at the basic numbers: 0.6% have anorexia, which has a mortality rate of 0.56%.
That means that of the 1.8 million Americans have anorexia, 1,710,000 are between the ages of 12 and 25. Of them, 9,576 will die this year. The CDC states that “16,375 teenagers 12-19 years died in the United States every year from 1999 to 2006.”
But Dan, do you know what the most common cause of death among anorexics is?
… the risk of death by suicide among by anorexic women to be as much as 57 times the expected rate of a healthy woman.
Likewise, obese and overweight teens have a higher rate of suicidal ideation than those in the normal BMI range.
Consider your message, Dan. What are you telling the many, many, many teenagers who read your column and look up to you? What do you say to the teenagers who are struggling with anorexia? What do you say to the teenagers who are struggling with being “too fat”?
You know what I hear? “It gets better… except for you fatty!”
So, when you say something like, “Most women don’t have the kind of bodies that look good in low-rise jeans, fat or not,” you are contributing to a culture that says that only one type of body is acceptable for public exhibition. You try to temper that comment by adding:
… pointing out that something isn’t flattering isn’t the same thing as saying that the person wearing the unflattering garment is unattractive
Fair enough. But when you begin to make such distinctions between what women should and should not wear, when you agree with the comment that nobody wants to see “fat rolls hanging over the tops of jeans or bulging out from under belly shirts,” you are sending a very clear message that society does not want to see the exposed flesh of fat women or women with fat rolls. You are sending a very clear message that, sure, you ultra-skinny babes can wear whatever the fuck you want, but fatties have to hide their bodies in “flattering” clothes.
To me, it sounds a whole fucking lot like people who say, “Hey hetero couples, we don’t mind if you make out in public, but you flaming homos can’t be all gayness and light in public.” Or, to bastardize your own words:
If North American homosexuals want to flounce around in leather chaps–and apparently we do–we should get the AIDS epidemic under control first.
It’s the same fucking ignorance, the same fucking hatred that you are fighting against on behalf of gay Americans. The only difference is that your aesthetic displeasure is on the other side of the fence now. Now you’re the one who feels disgusted and appalled by the public display of what you deem unattractive or unacceptable. And now you’re the one dispensing baseless conjecture, stereotypes and unfounded “science” to claim that your opinions, regardless of how hateful, are fully justified.
But despite all of this information, despite what I have shared, I do not think you are the enemy and I do not hate you or think you are a horrible person.
I think you’re an intentionally misinformed person, just like the rest of our society. You’ve been inundated with warnings and predictions of doom, and you are doing what you think is the responsible thing: encouraging people to lose weight and to not be so fucking fat.
But the people who know this issue best have a completely different understanding of why we are as fat as we are, and just what needs to be done about it.
Stigma and shame will not help. Pounding the “eat less, move more” drum will not help. Lecturing fatties on fashion faux pas will not help.
What will help is a more compassionate understanding of what health and obesity really means, and a less judgmental attitude toward those we deem “too fat.”
I’ve written this post to ask you — to beg you — to reconsider your current position on obesity and health because your current attitude is not helping, it is hurting many, many people. I believe that if anyone understands the terrible impact that ignorance (even well-intentioned ignorance) can have on others, it is you.
I look forward to hearing back from you and I hope that you have kept an open mind while reading this. I will be happy to answer any and all of your questions and challenges. This is a very important subject and I strongly believe that if we begin educating people on evidence-based treatment, rather than fear-based campaigns, we can improve the health of all people, not just the fatties.
Thank you for taking the time to read this long and rambling diatribe and I wish you the best.