Fat City
By E. Noel Preston, MD

   It's almost three o'clock on an August Saturday afternoon and every seat at the food court at Perimeter Mall is filled with a fat person eating french fries and slurping a cola drink. Most of these people are going to die years before everyone else. People who are overweight have more heart attacks, strokes, high blood pressure, and diabetes. They have more backaches and foot problems. And they have more cancers: not just the hormone-sensitive cancers, like cancer of the breast, uterus and cervix, but cancers of the digestive tract, like cancer of the rectum, colon, and stomach. These are going to be expensive people to take care of, and their families and insurance companies and we taxpayers are going to pay for their not having the sense to take care of themselves.

   What is the difference between being big, or heavy, and being fat? There are all sorts of height-weight charts and BMI (body mass index) cards, but the easiest way to tell if someone is dangerously overweight is to measure the waist at the bellybutton level. If an adult male's waist measurement is more than 40 inches or an adult woman's waist is more than 35 inches, that's medically obese (Incidentally, overweight pear-shaped men are more likely to die of heart disease, and overweight apple-shaped men are more likely to have cancer of the stomach). For children we have height-weight charts that tell us if a child's measurements are at the average for his or her age, or within one or two standard deviations from the average for that age. Measurements greater than two standard deviations from the average are regarded as abnormal and require medical attention.

   What makes people fat? Possibly it's genetic; but is someone fat because he's inherited it from his parent(s), or is he fat because his overweight parents have taught him to eat too much? Sometimes a parent of an overweight child asks me if the child might have an underactive thyroid gland, and once in a great while he does. But the thyroid controls growth more than it controls weight, and if a child is above the average height for his age, he does not have an underactive thyroid. To this day I have never seen an overweight child who is below the 50th percentile for his height. Occasionally someone might have had an underlying crippling disease in childhood such as polio, rheumatoid arthritis, muscular dystrophy, or a number of other problems, and these conditions can limit physical activity and the person gains too much weight as a result of not being able to get enough exercise. Adolescents frequently put on weight because for most of their young lives they have been more active than everyone else -- roller skating, bicycle riding, swimming, climbing trees, or running games like hide-and-go-seek or tag -- but now they sit on the couch and watch TV and eat potato chips and popcorn. They've become accustomed to eating a lot as an active child or an early teen, but now as less physically active mid-teenagers they eat the same as before and gain too much weight. It all comes down to a basic law of physics: obesity results when calories taken in as food exceed calories expended as exercise.

   So: what to do about it? It doesn't matter if you're on the Atkins diet, the South Beach diet, the Weight-Watchers diet, the Slim-Fast diet, or any other diet. The answer is eat less and exercise more. That's all there is to it. But how to do this? How do you make this simple idea work?

   The British have become alarmed at the growing rates of obesity in American school children. They don't want their own children getting obese, and they don't want their citizens straining their already overburdened National Health Service with obesty-related or obesity-caused diseases -- and so they have taken soft drink vending machines out of the schools, they provide low-fat lunches with fruits and vegetables, and they have expanded their physical education classes. Once upon a time in America we had a program called the Presidential Physical Fitness Award, which was presented to elementary school children who could perform certain physically demanding tasks in a specified time period. I think it's time we revived it.

   Here in Atlanta, Dr. Scott D. Isaacs, a specialist in Diabetes, Endocrinology, and Metabolism, presented a seminar for doctors at Northside Hospital last month on dietary control of obesity, and he does advocate a reduction in dietary calories -- but in a nutshell, his program requires two special tasks: walk two miles a day (or 10,000 steps or 30 minutes of brisk walking), and eat 45 helpings of fruit or vegetables every week. 45 helpings of fruit or vegetables a week??? There are only seven days a week -- how can anybody do that? Well, if there are three meals a day, that's 21 meals a week, and if you have two helpings of fruit or vegetables at each meal, you're up to 42 helpings a week right there. Throw in a couple of afternoon snacks of dried fruit or cereal every afternoon instead of potato chips, candy or popcorn, and you''re home free. People with diabetes who have required insulin for years have been in this program and have seen their requirements for insulin diminish and even disappear. Blood pressures go down and cholesterol levels drop. It's astonishing how much healthier people can be just by returning to a normal weight.

   There are a variety of reasons fat people make other people nervous, angry, uncomfortable, or hostile. When I was a student at Emory Medical School, the psychiatry professors taught us that if we believe fat people eat too much, subconsciously we are afraid they might eat all the food there is so there wouldn't be any left for the rest of us, and, that after they ate all the food, they might eat us next! They also said that if we find a lost puppy or child or someone in great distress, one of the first things we do is offer the poor creature some food. By doing so we are saying we care about you, we love you, and we want to help you. But people who are fat, according to this theory, cannot believe anyone cares about them and so they think "no one else cares whether I live or die, no one loves me, no one is going to help me or feed me, but I love myself, I care about myself, and if no one else will feed me, I will! " And so we think of fat people as being self-centered and unable to delay gratification, and thus less likely to perform well at their work or pay attention to anyone else's concerns. As a doctor, I think the human body is one of the most beautiful creations on earth, and just as a mechanic gets irritated seeing someone abuse a finely tuned and engineered automobile, I get irritated seeing people abuse their bodies -- and it saddens me to see someone ruining his health, shortening his life, and bringing trouble and heartache to himself and his family -- and it doesn't have to be this way.

E. Noel Preston, M.D. is a pediatrician in solo practice in Peachtree Corners. 6063 Peachtree Parkway, Suite 202-A, Norcross. (770) 448-1553.

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