The Obesity Paradox

Carl J. Lavie, Kristin Loberg

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Everyone has a clear picture of what obesity looks like. The word originated in the seventeenth century from Latin: obesus, which literally means “having eaten until fat.” The Oxford English Dictionary documents its first usage in 1611 by Randle Cotgrave, an English lexicographer who compiled a bilingual French and English dictionary. We may think that obesity is a relatively new disease that emerged in the late twentieth century, but it dates back to the prehistoric era. Twenty-five to thirty-five thousand years ago, the first sculptural representations of the human body depicted obese females. At various times over the centuries it has stood for wealth or stature, or even luck, in the case of plump Venus figurines used in primeval rituals. When it was deemed good and a sign of health, it typically signaled that someone was living a privileged life and didn’t go hungry. That person was also likely to be just moderately overweight or mildly obese—not morbidly so, as we see among 3 percent of the US population today. ­­And at other times throughout history, obesity has been looked upon  as a negative attribute, a character flaw, and an insult to health. In the sixth century BC, the Indian surgeon Sushrutha related obesity to diabetes and heart disorders. Sushrutha is actually considered the father of plastic surgery today, made famous for not only his nasal reconstructions at a time when medicine was in its infancy, but also for his futuristic understanding of human anatomy, physiology, disease, and relevant therapies.

Virtually every culture on the planet has recorded this age-old condition, from the ancient Egyptians and ancient Chinese to the Aztecs and Hippocrates, the father of modern  medicine, who wrote around 450 BC (about 150 years after Sushrutha) that “corpulence is not only a disease itself, but the harbinger of others.” These formal writings credited the Greeks with first recognizing obesity as a medical disorder.

Only in the past forty years has obesity become much more prevalent . . . and much more demonized by society. Well over 70 percent of us are now overweight or obese (compared with less than 25 percent some forty years ago); less than a third of us are considered at a “healthy weight.” But what, exactly, does that mean? What constitutes a healthy weight? In fact, what constitutes the word weight? Can having a lot of muscle mass and, therefore, a high body mass index (BMI) necessarily equate with “obesity”?

Before we can even begin to address such questions, it helps to understand that all these terms—obesity, health, weight—are very loaded words and perhaps always have been. How we define each of these depends a lot on context. Contrary to what you might think, the definition of obesity, or just being overweight, remains controversial. In the US, mortality data provided by the Metropolitan Life Insurance Company (MetLife) historically has been used to define obesity. In fact, the entire concept that excess weight can make for an early grave first came from studies done by our country’s insurance industry, not the medical community. Insurance companies may not be in the business of healing, but they are perfectly suited for the task of figuring out who is likely to die sooner rather than later. Yet their data related to mortality only—the chance that someone would die based on his or her body weight.  This definition depends solely on a person’s frame  (i.e., size, as defined by weight and height).

You might recall seeing versions of the charts created by MetLife and prominently displayed in doctors’ offices when you were growing up. The chart listed the difference between small, medium, and large body frames based on height in inches and weight in pounds. Its purpose was to give ideal body weight values and provide an estimate of body fat composition. But how we came to draw the lines among “small,” “medium,” and “large” (and, for that matter, normal versus obese, since only height and weight measurements were considered) was quite arbitrary. The original definition was not connected to or based on obesity-related diseases or death.

Today we equate obesity with epidemic, and as such we define and conceptualize it differently than ever before. Indeed, the obesity epidemic as we give meaning to it in the twenty-first century is not particularly old. Although obesity in adults and children, male and female, has doubled over the past forty years, the biggest increase has been since 1980. Prior to this, evidence of the obesity epidemic was hardly identifiable. Obesity rates among children born between the 1930s and most of the 1970s, for example, remained low and steady. And then the numbers started to go upward rapidly through the 1980s and 1990s.

The Obesity Paradox Carl J. Lavie, Kristin Loberg