Overweight and Obesity

by JEAN MAYER

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ONE of the products of present-day obsession with overweight has been the wide publicity given to tables which provide “normal,” “ideal,” or “desirable” weights for stated heights and, sometimes, for stated ages. To use these tables, it would appear that all you have to do is to know your height. You can then read the weight at which, at best, you will be considered most “desirable” and, at worst, you will be “normal” for your age. Knowledge of your physical type (“big-boned,” “delicately built,” “average,” or whatever) should enable you to choose the appropriate “frame” column. If you are above the stipulated weight you are too fat. Your chances of having heart disease, hernia, or diabetes and of losing t he affect ion of your loved ones are multiplied; you must diet. If you are below the stipulated weight you are too skinny. You are the prey of similarly horrifying diseases, if not of equally catastrophic events; you must stuff yourself.

Life insurance companies and, in particular, Dr. Louis Dublin, the eminent statistician of the Metropolitan, deserve great credit for having repeatedly called attention to the very serious risks which accompany obesity. Using the data at their disposal heights and weights of applicants for policies and causes of death of policyholders — they have arrived at the conclusion that “the greater the overweight, the greater the curtailment of longevity.” Overweight men and women are found to be four times as likely to die of diabetes as are standard risks. Their mortality from chronic nephritis, cerebral hemorrhage, and coronary disease is twice the normal.

On the other hand, overweight individuals, according to the same insurance studies, are less prone to suicide than are normal-weight individuals. Apparently the physical and the mental make-up which are favorable to the development of obesity are unfavorable to the development of the suicidal state. The strikingly low rate of tuberculosis among the overweight—one fifth the standard in men, one third in women —may reflect not the protective effect of obesity but the deleterious impact of infection on appetite. Incidentally, the association of obesity and infrequent deaths from tuberculosis may explain why for so long stoutness was, in the Western world, equated with health.

The relation of obesity and the degenerative (noninfectious) diseases may be equally complex. In some cases the excess fat is obviously dangerous per se; it increases surgical risk, making administration of anest hesia more delicate, as well as causing operations to be performed through layers of fat. It increases the probability of liver disease because the organ may become a foie gras. Increased deaths from accidents can be a consequence of the fact that the obese individual is a larger, clumsier, and slower target as well as a poorer surgical risk after an accident.

Obesity’s relation to heart disease may well be even more complicated. Excess fat may directly cause peripheral circulation to be more difficult and may impair the function of the heart. Obesity and deficient cardiovascular function may also be the common effects of a sedentary, sluggish mode of life, The association of diabetes and middle-age obesity may represent common symptoms of a complex obesity-diabetes syndrome.

Even though the relation of obesity to disease is probably not always as directly causal as it is pictured, there is no doubt that Dr. Dublin and his associates have overwhelming evidence for their formidable indictment of obesity. Moreover, a recent study has shown that obese individuals who reduce and stay reduced may thereby substantially increase their life expectancy. Dublin’s studies clearly show that “the best longevity record, especially for men in later life, was recorded for those who were greatly underweight.

The tables of “normal” or “standard" weight most commonly found in the United States do not tell us what we need to know about obesity. To begin with, they were compiled by Charles B. Davenport for the medico-actuarial survey of 1912. Heights were recorded with shoes on, weights with street clothes on (1885-1900 clothes at that). So many of the weights ended in 0 and 5 that some observers have concluded that the weights were estimated, not measured. There is an even greater element of uncertainty when the phrase “with shoes on” is applied to the women of that period. The weight of women’s street clothes must also have been more variable from year to year in that era, which saw rapid changes in women’s fashions.

At the end of the nineteenth century the practice of buying life insurance was not nearly as widespread as it is now. It was confined to a relatively small group of prosperous individuals. When you are using the “normal” weight table and comforting yourself with the thought that your weight is “normal for your height and age,” remember that you arc pitting yourself against bankers, brokers, lawyers, and physicians of the gay nineties, complete with handlebar mustaches, vests, striped pants, morning coats, spats, watch chains, and carnations.

The Metropolitan Life Insurance Company tables are based on the 1912 figures modified in the following way: The weights for men arc predicated on their “standard” weights at age thirty, on the theory that any increase from then on is bound to be pure adipose tissue. For the banker-broker types who dominate the 1912 figures, several years of sedentary life have often already enlarged the abdominal girth by the age of thirty.

Because it was felt that the 1912 tables tended to overestimate the correct body weight of tall people and to underestimate that of short ones, corrections were brought to bear. Further adjustments were made to smooth the gradation of values at successive heights. Then groups were set up on both sides of the figures thus obtained. The three columns so arbitrarily achieved were sent out into

the world handsomely designated as “ideal weights for individuals endowed respectively with “small,” “medium,” and “large” frames. The term “ideal” has recently, for reasons unclear to me, been changed to “desirable.”

It must be noted that the weights for the various

frames were never based on actual measurements of individuals classified by frame. As a matter of fact, no method is given to enable us to measure the size of our frame. Worse, the term is never defined. Is it purely a matter of skeletal size? Is it muscular development? Is it a function of both.’ How well is obesity correlated with overweight? Is it impossible to measure fatness itself? Certainly, there is no doubt that the 400-pound man is overfat whatever his degree of muscular development. But what of the middle ranges? Is the portrait of Herman Hickman as a young man that of one of the greatest athletes of his time or that of one condemned to rapid physical decay by excess fat? Methods recently developed supply an answer, at least in part, to these questions.

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ABOUT half of the total fat of the body is found just under the skin, and therefore it generally shows. Cursory visual examination of a person will often tell you whether the subject is or is not fat. Judicious pinches in appropriate places can settle many cases where observation alone is inconclusively informative. Thickness of fat layers in the chin, abdomen, chest, and arms has been found to be most closely correlated to the degree of fatness of the whole body. There are differences in localization of subcutaneous fat of children and adults — small children have more fat on the arms than on the abdomen; adults show the opposite picture. There are differences, too, between men and women. To give but one example, an educated pinch on the calf of the leg is more revealing of total body fat in women than in men.

There is a sophisticated technique which permits us to express the results of pinches in proper numerals; a caliper of standard dimensions, which pinches with a standard amount of pressure, is a necessary auxiliary of the scientific pincher. Simple observation can also be refined by the use of X rays. Soft-tissue roentgenograms show the fat layers at the sides of the X-ray profile.

If we can measure the density of a human body we can calculate the total amount of fat in the body because of the low specific gravity of adipose tissue. Weighing people first in air and then under water is a method hinted at by Archimedes. It was pioneered by a F.S. Navy captain, Dr. Albert R. Behnke, Jr., who is recognized as the outstanding specialist of submarine medical services. Further refinements have been devised by Ancel Keys, the Minnesota physiologist, and his co-workers. There are yet other ways to get some useful idea of the body’s fat content, such as estimation from the weight and the total body water determined by injecting a small amount of heavy water in a vein and measuring its dilution after sufficient time has elapsed for it to be uniformly diluted by ordinary water molecules.

These methods have made it possible to demonstrate the differences in fat content between the sexes, between age groups, and between sedentary workers and those employed more strenuously, and to differentiate between overweight and obesity. It has been shown, for example, that women twentyfive years old contain at least 50 per cent more fat than young men of the same age. Thin forty-yearold women may contain up to twice as much fat as muscular men of the same age. A picturesque determination conducted by W. C. Welham and Albert Behnke, Jr., confirms the fact that overweight and obesity are not synonymous. The average tackle or guard on a college or professional football team weighs 200 pounds or more. Even in relation to his height and even when he is considered as falling in the “large frame” class, the six-foot, 200-pound lineman is at least 10 per cent overweight according to the “ideal” table. Yet, when the Navy scientists measured the specific gravity of seventeen professional football players, several of them former All-Americans, they found them endowed with a greater than normal specific gravity, indicating an abnormally low fat content. These overweight men were underfat.

Aging in the adult is of particular interest. The tables of “normal” height-weight appeared to condone the progressive acquisition during maturity of surplus poundage. It can be made clear by these new techniques that such accumulated weight after completion of muscular and skeletal growth is nothing but useless or dangerous fat.

Even if the same weight is maintained throughout adult life, active tissue is progressively replaced by fat. In other words, even if our body weight does not change, we become increasingly fatter as we grow older. Keys matched thirty-three younger (22 to 29 years) men and thirty-three older (48 to 57 years) men so that each young man was paired with an older man of the same height and weight. The fat content of the older men was found to be 50 per cent greater than that of the younger men. Women, it has already been seen, are proportionately fatter than men at all ages, but the evolution of their fat content shows an increase with age parallel to that of the leaner sex. Active individuals who continue to exercise into middle age maintain a proportionately greater lean body mass than do sedentary people. Even in the active individuals, however, age inexorably infiltrates existing tissue with fat. For all of us, but perhaps particularly for highly muscular individuals who stop intensive exercising, it would appear that the only way We can decrease the rate of progressive accumulation of fat is (far from following the “normal” height-weight tables) to stop our weight gain at the age of twenty-five and, oxer the later years, slowly to lose weight. In other words, we should attempt to do what the French call vieillir sec, “to age dry.”

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ELABORATE scientific studies thus confirm that appearance of the silhouette and firmness of superficial tissues are a better index of obesity than weight. This was forcibly brought home to me in India, a land characterized by an extreme diversity of human types. Most Bengalis, whether owing to genetic traits or to deficient diets in childhood, have an extremely slight build. The jute workers I examined showed a frail and narrow skeleton as well as a poorly developed musculature. The average weight for men was about 110 or 115 pounds for a height of five feet, two inches, to fixe feet, fixe inches. Even among individuals who were engaged in heavy physical work, muscular development was often limited to the muscles directly inxolved in the work. Under these conditions, it is little wonder that Bengali factory workers, xvhose weight conforms to the “ideal” even for the “light” frame, appear obese on xisual examination and feel fat xvhen pinched. Conversely, the massive Sherpa porters of Nepal or Darjeeling can weigh 50 pounds more than the frail Bengali of the same height without appearing fat and without impairment of performance.

In the West the recent tendency has been toward the “desirability” of thinner and thinner women. The average American woman gazes daily at fashion adxertisements designed to prove to her how xvell clothes look on women sexeral inches taller and many pounds thinner than she can ever hope to be. The fact that people tend to photograph “fat” has touched off among movie actresses a self-accelerating chain reaction toward slenderness. The net result has often been favorable, as it. has tended to make many Western women adopt drastic and often effective measures to conform to prevalent clothing fashions. Thus Dior has often succeeded where health education has failed. On the other hand, the desire to achieve the figure of Lauren Bacall has led many girls in their teens and twenties 1o starve themselves into a state of physical weakness and headache and has led young mothers to eschew nursing their babies for fear that more rounded contours might follow.

It is a truism that men are less sensitive to obesity — in themselves — than women are. A few years ago a Gallup poll indicated that, while a substantial proportion of American women considered themselves to be oxerxveight, American men were generally satisfied with their anatomy. However, the evolution of weight statistics in the course of the past half century would suggest that relatively more men than women, perhaps twice as many, have entered the ranks of the obese. Aesthetics is probably a deciding factor. Physical appearance plays a greater role in the appraisal of women than it does of men. Furthermore, modern dresses are very revealing of figures; a small increase in the waist circumference renders a dress unusable. By contrast, men’s clothing is sufficiently shapeless to mask men’s physiques. Military uniforms are usually tighter, but then a large chest girth is an asset for the display of decorations, as is demonstrated by the obese uniformed totalitarian figures who have become such a characteristic fixture of our century. The male indifference to overfatness is all the more serious because obesity may well be even more detrimental to the health of men than to that of women. Thus, the need for clear-cut (but sensible) standards of fatness is even greater for men than for women. Such standards should guide those men who have ceased to care about their appearance or who have developed self-delusions about their muscular development.

We may hope that insurance companies and other health-minded agencies will continue their efforts and will adopt more accurate criteria of fatness than they have used in the past. We may also hope that progress in the understanding of the physiology of disturbances of appetite will elicit their relation to disease. In particular, the following problem may thus be solved. Will the six-foot, 200-pound overweight athlete stay in the same risk category as the sedentary overfat individual of the same height and weight ? Is it as bad to carry too much muscle as too much fat? Or, on the contrary, will it be discovered that if disease wore correlated with fatness rather than weight, the correlation would be even more striking? Certainly the improvement in risk due to losing weight—in this case weight must be synonymous with fat — would suggest that the latter hypothesis may be correct, but we have no final proof of this.

Certain European clinicians maintain that the location of the excess fat may be correlated with certain specific risks. For example, the android (John Bull) type of obesity, with the excess fat predominantly located in the upper part of the body, has been characteristically associated with high blood pressure. It is to be hoped that simple methods will soon be devised to test this theory.

If you are really fat, you should be able to see it and to feel it. To be specific, if you are a man, if the fat under your chin is thicker than your thumb, if when you pinch your abdomen you can collect a fat fold more than an inch thick, you are probably too fat for your own good. By contrast, if you are “all muscle,” with a weight above the “ideal” for your height, and if you — or a less biased observer such as your wife or, better still, your physician — are sure that it is muscle, forget about your ideal weight. Remember, nevertheless, in this case that if you cease your physical activity you are especially exposed to replacement of muscle by fat and you had better plan to age dry by progressively losing weight.

Above all, remember this simple rule. Your safest guide as to what you should weigh is not a table based on the estimated weights of a selected group of fully clad professional men of a bygone era, but it is what you, yourself, weighed at the peak of your physical form, when you were about twentyfive. At that age both your bones and your muscles had stopped growing. Unless you were suffering from tuberculosis and muscular wasting at the time, any weight you have put on since is pure fat. Furthermore — particularly for men, who don’t have the excuse of repeated pregnancies and of menopausal changes — it is a weight that you should be able to maintain, without undue suffering, by diet and regular exercise. So get back there and stay there!

The minority of people who did not become fat as a result of a creeping process in the middle years due to physical inactivity and accessibility of food, but who were obese through childhood and youth, present a much more difficult problem. In these cases the weight at twenty-five may not be the proper guide. Suffice it to say that the weight which should represent their target is a matter for the judgment of their physician and not something that can be read off the subway scales.

Dr. Mayer’s third article, “Appetite and Obesity,” will appear in the September Atlantic.