Why We Get Fat: And What to Do About It (5 page)

“There is no mistaking the general picture”—he later writes—
“a little lean meat once or twice a week was the rule, butter was almost unknown, milk was never drunk except in coffee or for infants, ‘colazione’ [breakfast] on the job often meant half a loaf of bread crammed with baked lettuce or spinach. Pasta was eaten every day, usually also with bread (no spreads) and a fourth of the calories were provided by olive oil and wine. There was no evidence of nutritional deficiency
but the working-class women were fat
.”

What Keys didn’t say was that most people in Naples and in fact all of southern Italy were exceedingly poor at the time. The Neapolitans had been devastated by the Second World War, so much so that a tragic sight during the latter years of the war was lines of mothers and housewives prostituting themselves to Allied soldiers to get money to feed their families. A postwar parliamentary inquiry portrayed the region as essentially a third-world nation. There was little meat to be had, which was why little meat was consumed, and malnutrition was common. Only by the late 1950s, long after Keys’s visit, did reconstruction efforts begin to show any significant progress.

One other fact worth noting is how closely Keys’s description of the Neapolitan diet matches the Mediterranean diet that is all the rage these days, even down to the copious olive oil and the red wine, or the grandmotherly diets that Michael Pollan recommends in
In Defense of Food:
“Eat food, not too much, mostly plants.” Certainly these people were eating not too much. A 1951 survey ranked Italy and Greece as having less food available per capita than any other countries in Europe—twenty-four hundred calories daily, compared with thirty-eight hundred calories available per capita in the United States at that time. And yet “the working-class women were fat.” Not the rich women but the ones who had to work hard for a living.

Bureau of Indian Affairs researchers weigh and measure the Pima children and report that more than half, boys and girls both,
are obese by age eleven. Living conditions on the Gila River Reservation: “Widespread poverty.”

Among African Americans, 18 percent of the men and 30 percent of the women are obese. Cash incomes for the heads of families range from $9 to $53 per week, or the equivalent of about $65 to $390 per week today.

Among Zulu, 40 percent of the adult women are obese. Women in their forties average 175 pounds. The women, on average, are twenty pounds
heavier
and four inches
shorter
than the men, but this does not mean they are better fed—excessive adiposity, the researchers report, is often accompanied by numerous signs of malnutrition.

A local physician describes the situation bluntly: “By European standards, everyone past puberty is grossly overweight.”

A team of nutritionists from the United States reports that malnutrition is a serious medical problem on the island, but so is obesity. Nearly a third of the women older than twenty-five are obese. The average caloric intake among these women is estimated at fewer than two thousand calories a day—
less than the minimum
recommended at the time by the Food and Agriculture Organization of the United Nations as necessary for a healthy diet.

Obesity is described as “the main nutritional problem of Chilean adults.” Twenty-two percent of military personnel and 32 percent of white-collar workers are obese. Among factory workers, 35 percent of males and 39 percent of females are obese. These
factory workers are the most interesting, because their jobs quite likely involve significant physical labor.

Researchers from the South African Institute for Medical Research study urban Bantu “pensioners” older than sixty—“the most indigent of elderly Bantu,” which means the poorest members of an exceedingly poor population. The women in this population average 165 pounds. Thirty percent of them are “severely overweight.” The average weight of “poor white” women is also reported to be 165 pounds.

Twenty-nine percent of adult Cherokee on the Qualla Reservation are obese.

Twenty-five percent of the women and 7 percent of the men attending medical outpatient clinics in Accra are obese, including half of all women in their forties. “It may be reasonably concluded that severe obesity is common in women aged 30 to 60,” writes an associate professor at the University of Ghana Medical School, and it is “fairly common knowledge that many market women in the coastal towns of West Africa are fat.”

Five percent of the men are obese, as are nearly 30 percent of the women. Of women between fifty-five and sixty-five, 40 percent are very obese.

Forty percent of the adult women are obese; 25 percent are “grossly obese.”

Rolf Richards, a British-trained physician running a diabetes clinic at the University of the West Indies, reports that 10 percent of the adult men in Kingston and two-thirds of the women are obese.

A nutritionist from the Catholic University in Santiago reports on a study of thirty-three hundred factory workers, most engaged in heavy labor. “Only” 11 percent of the men and 9 percent of the women are “severely undernourished”; “only” 14 percent of the men and 15 percent of the women are “severely overweight.” Of those forty-five and older, nearly 40 percent of the men and 50 percent of the women are obese. He also reports on studies in Chile from the 1960s, noting that “the lowest incidence [of obesity] exists among farm workers. Office workers show the most obesity, but it is also
common among slum dwellers.
”

Kelly West, the leading diabetes epidemiologist of the era, reports of the local Native American tribes that “men are very fat, women are even fatter.”

On the Mexican border, two hundred miles south of San Antonio, William Mueller and colleagues from the University of Texas weigh and measure more than eleven hundred local Mexican-American residents. Forty percent of the men in their thirties are obese, although most of them are “employed in agricultural labor and/or work in the oil fields in the country.” More than half the women in their fifties are obese. As for the living conditions, Mueller later describes them as “very simple.… There was one restaurant [in all of Starr County], a Mexican restaurant, and there was nothing else.”

So why were they fat? What makes the overeating, calories-in/calories-out argument so convenient—suspiciously so—is that
it always provides an answer to this question. If the population was so poor and malnourished that even the most stalwart believer in immoderate eating as the cause of obesity will have trouble imagining that they had too much food available—the Pima, for instance, in the 1900s or 1950s, the Sioux in the 1920s, the Trinidadians, or the slum dwellers of Chile in the 1960s and 1970s—then it can always be claimed that they must have been sedentary, or at least
too
sedentary. If they were obviously physically active—the Pima women, the Chilean factory workers, or the Mexican-American agricultural laborers and oil-field workers—then it can be claimed that they ate too much.

The same arguments can and will be made for individual cases as well. If we’re fat and we can prove that we eat in moderation—we don’t eat any more, say, than do our lean friends or siblings—the experts will confidently assume that we must be physically inactive. If we’re carrying excess fat but obviously get plenty of exercise, then the experts will assume with equal confidence that we eat too much. If we’re not gluttons, then we must be guilty of sloth. If we’re not slothful, then gluttony is our sin.

These claims can be made (and often are) without knowing a single other pertinent fact about either the relevant populations or individuals. Indeed, they’re often made with little desire or inclination to learn more.

In the early 1970s, nutritionists and research-minded physicians would discuss the observations of high levels of obesity in these poor populations, and they would occasionally do so with an open mind as to the cause. They were curious (as we should be) and hesitant to insist they knew the answer (as we should be).

This was a time when obesity was still considered a problem of “malnutrition” rather than “overnutrition,” as it is today. A 1971 survey in Czechoslovakia, for instance, revealed that nearly 10 percent of the men were obese and a third of the women. When these data were reported in conference proceedings a few years
later, the researcher who did so began with this statement: “Even a brief visit to Czechoslovakia would reveal that obesity is extremely common and that, as in other industrial countries, it is probably the most widespread form of
malnutrition.
”

Referring to obesity as a “form of malnutrition” comes with no moral judgments attached, no belief system, no veiled insinuations of gluttony and sloth. It merely says that something is wrong with the food supply and it might behoove us to find out what.

Here’s Rolf Richards, the British-turned-Jamaican diabetes specialist, discussing the evidence and the quandary of obesity and poverty in 1974, and doing so without any preconceptions: “It is difficult to explain the high frequency of obesity seen in a relatively impecunious [very poor] society such as exists in the West Indies, when compared to the standard of living enjoyed in the more developed countries. Malnutrition and subnutrition are common disorders in the first two years of life in these areas, and account for almost 25 per cent of all admissions to pediatric wards in Jamaica. Subnutrition continues in early childhood to the early teens. Obesity begins to manifest itself in the female population from the 25th year of life and reaches enormous proportions from 30 onwards.”

When Richards says “subnutrition,” he means there wasn’t enough food. From birth through the early teens, West Indian children were exceptionally thin, and their growth was stunted. They needed more food, not just more nutritious food. Then obesity manifested itself, particularly among women, and exploded in these individuals as they reached maturity. This is the combination we saw among the Sioux in 1928 and later in Chile—malnutrition and/or undernutrition or subnutrition coexisting in the same population with obesity, often even in the same families.

Here’s that same observation discussed more recently but now steeped in the paradigm that overeating is the cause of obesity. This is from a 2005
New England Journal of Medicine
article, “A Nutrition Paradox—Underweight and Obesity in Developing Countries,” written by Benjamin Caballero, head of the Center
for Human Nutrition at Johns Hopkins University. Caballero describes his visit to a clinic in the slums of São Paulo, Brazil. The waiting room, he writes, was “full of mothers with thin, stunted young children, exhibiting the typical signs of chronic undernutrition. Their appearance, sadly, would surprise few who visit poor urban areas in the developing world. What might come as a surprise is that many of the mothers holding those undernourished infants were themselves overweight.”

Caballero then describes the difficulty that he believed this phenomenon presents: “The coexistence of underweight and overweight
poses a challenge to public health programs
, since the aims of programs to reduce undernutrition are obviously in conflict with those for obesity prevention.” Put simply, if we want to prevent obesity, we have to get people to eat less, but if we want to prevent undernutrition, we have to make more food available. What do we do?

The italics in the Caballero quote are mine, not his. The coexistence of thin, stunted children, exhibiting the typical signs of chronic undernutrition, with mothers who are themselves overweight doesn’t pose a challenge to public-health programs, as Caballero suggested; it poses a challenge to our beliefs—our paradigm.

If we believe that these mothers were overweight because they ate too much, and we know the children are thin and stunted because they’re not getting enough food, then we’re assuming that the mothers were consuming superfluous calories that they could have given to their children to allow them to thrive. In other words, the mothers are willing to starve their children so that they themselves can overeat. This goes against everything we know about maternal behavior.

So what’s it going to be? Do we throw out everything we believe about maternal behavior so we can keep our beliefs about obesity and overeating intact? Or do we question our beliefs about the cause of obesity and let our beliefs about the sacrifices mothers will make for their children remain intact?

Again, the coexistence of underweight and overweight in the
same populations and even in the same families doesn’t pose a challenge to public-health programs; it poses a challenge to our beliefs about the cause of obesity and overweight. And it shouldn’t be the only thing that does, as we’ll see in the chapters that follow.