The Fat of the Land: The Obesity Epidemic and How Overweight Americans Can Help Themselves

  • Michael Fumento
Viking: 1997. Pp. 330 $25.95
Gone to waist? Perception of risk is one of the main barriers to the health hazard of obesity being universally accepted. Credit: FRANK HERHOLDT/GETTY IMAGES

The epidemic of obesity imposes a heavy burden on the healthcare systems of many industrialized countries, contributing up to 10% of total health costs. The United States leads the way, with a third of the population classified as obese, but Europe is catching up rapidly. Why? What should be done to stem the rise, and how should we treat those who are already obese?

Michael Fumento is a medical journalist who, frustrated by his own repeated cycles of weight loss and regain, has immersed himself in the medical, scientific and general literature on obesity. He learnt the facts about the obesity epidemic: its probable causes, the risks obesity poses for the individual, and the many claims for cures, ranging from the latest diets and drugs to outrageous quackery. Finally, he managed to lose weight and keep it off. The book is a summary of this literature, interspersed with personal observations and anecdotes and his own (sometimes controversial, and often not politically correct) solutions to the problem.

Perception of risk, as Fumento recognizes, is one of the main barriers to the health hazards of obesity being universally accepted; people worry more about alar on apples, radon gas or BSE than about obesity, yet it kills 300,000 Americans a year. They are confused by the mixed messages coming from the media, advertisers, the food industry, ‘experts’ in the slimming industry and the ‘fat acceptance’ lobby, each with their own agendas and vested interests. Fumento sees the success of ‘miracle’ diet books, products that claim they cause fat to ‘melt away’, or electrical pads that burn calories by ‘stimulating minute muscle contractions’ as a symptom of people's willingness to believe in anything that allows them to lose weight without changing their behaviour.

Why is obesity increasing? The population is eating more and exercising less. Labour-saving devices, especially cars, and the food industry are the usual suspects, and plenty of evidence is given to convict them. Low-fat foods and artificial sweeteners are discussed and seen as an excuse to eat other high-calorie foods rather than as a solution.

Unfortunately, some important scientific issues are dismissed or glossed over. Genetic differences are clearly not the cause of the current epidemic of obesity, but they may nevertheless be important. Twin studies have shown that the tendency to gain weight in response to overfeeding is largely inherited. Some people gain weight more easily than others and find it harder to lose, which may partly explain why diet and exercise do not work equally well for everybody. And there is no mention of the hypothesis proposed by Barker and Hales that suggests that smaller babies are more prone to many of the medical problems associated with obesity, such as diabetes, hypertension and heart disease, because of fetal metabolic programming. The current demographic bulge in the adverse effects of obesity (and possibly in the tendency to gain weight when food is plentiful) may therefore lessen in future generations as the nutritional state of mothers improves.

The solutions proposed and advice given by Fumento are generally sound. Yet teaching people the basic principles of energetics and then persuading them to eat less and exercise more may not be enough. Even with the best behavioural programmes, only a small percentage of people maintain their weight loss in the long term. These successful dieters and exercisers (such as Fumento himself) are rightly highlighted, and I would agree that more work needs to be done to discover why these people succeed while most do not.

Fumento understands that obesity is a serious medical problem, yet he is wary of medical solutions. Since the book was published, the appetite-suppressant drugs fenfluramine and dexfenfluramine have been withdrawn because of reports of their involvement in valvular heart disease, particularly when taken in combination with phentermine. Some new drugs are discussed, such as the intestinal lipase inhibitor orlistat, which reduces the absorption of fat, but sibutramine, a serotonin and noradrenaline reuptake inhibitor, is not mentioned.

Despite Fumento's scepticism, the rapid development of scientific and commercial interest in obesity may yet uncover new ways to help weight loss; I feel it is too early to dismiss a pharmacological solution. Strangely, surgical treatments are not mentioned at all, although they produce the most dramatic weight loss and provide the best evidence that losing weight is beneficial to health.

I enjoyed this book, which is a refreshing alternative to other popular books that discuss weight and how to lose it. It is amusingly written, but the humour at the expense of the obese may alienate those it seeks to help. Fumento sees this humour as a tool for a change in society, like the effect peer pressure has had on smoking in some groups. But perhaps it is the environment we have created that is at fault, not the individual. I agree that obese people must take on the responsibility of changing themselves, but there is a fine line beween persuasion and persecution.