Fat Land: How Americans Became the Fattest People in the World - Hardcover

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 Harper’s 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.

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.