09/19/2014 05:27 pm ET Updated Nov 19, 2014

Thicker Middles, Skulls to Match

We are, it seems, still getting fatter after all. I am yet again compelled to quote the immortal words of Iago the parrot: I am going to have a heart attack and die from THAT surprise.

This tale must be qualified by "after all" because we were told obesity rates had stabilized. Recent studies in adults indicated a plateau. Recent studies in children suggested much the same, with one report by the CDC indicating even slight declines in select locations, and another study hinting at a decline in children ages 2 to 5.

Of course, even that apparent good news was somewhat tainted all along by the accompanying fine print. What we actually thought we knew was that the numbers of us categorized as "overweight" or "obese" had stabilized, while the degree of overweight and obesity had not. The rate of severe obesity, in both adults and children, was known to have been rising steeply all along.

This is of profound importance for a number of reasons. First, at some level, obesity rates had to plateau. Maximally, that level would be 100 percent of the population. But it stands to reason that some measurable minority of us would be natively resistant to obesity. So an inevitable plateau, once we reached it, might simply mean that every vulnerable individual was already a victim, and anyone not caught up in the mess already was constitutionally (genetically) invulnerable. With close to 80 percent of the adult population overweight or obese, it's not far-fetched to think we were near that line.

Second, we are now well aware that minor degrees of overweight may pose little if any health threat. The menace of obesity to health correlates, predictably, with severity. So while a transition from normal to minimally overweight might increase the numbers of overweight, it might not reliably indicate a worsening threat to public health. In contrast, worsening degrees of obesity among those already affected would not show up in a prevalence measure, but certainly would indicate a growing public health threat.

We have known, or thought we knew, for some time that we were in that very situation. It was no longer reflecting the severity of the obesity epidemic to ask: "How many more are overweight or obese?" We had to start asking: "How much more overweight and obese are the many?"

The answer wasn't good. Rates of severe obesity, as noted, were rising relentlessly all along, and affecting populations around the globe. Consequences included increasing recourse to bariatric surgery even in children.

So whatever good news we thought we had was clearly rather blighted. But now, it seems, even that good news may have been misleading.

In a new study, Earl Ford and colleagues looked beyond the BMI, at waist circumference. Waist circumference is established as a better indicator of the health risks of obesity, since weight accumulated around the middle tends to be the dangerous kind.

Ford and colleagues found an increasing prevalence of elevated waist circumference, even in the absence of a rising prevalence of elevated BMI. In other words, even without necessarily getting heavier, we are getting fatter in the least healthy way. So the true rate of the kind of "obesity" that matters most, the kind that threatens health, is still rising after all.

As to why our waists are thickening preferentially, there is no decisive answer. Dr. Ford and colleagues speculate in their article about a number of potential explanations. I am inclined to think that a shift toward diets featuring ever more high-glycemic starches and added sugars is among the smoking guns. High glycemic diets trigger elevations of insulin, and among its many effects, insulin favors the deposition of calories around the middle.

And at that point, the plot thickens along with our waistlines. The deposition of those excess calories as fat around our middles, and in particular in our livers, leads directly to insulin resistance, and higher levels of insulin still. That, in turn, fosters more accumulation of centrally distributed fat, and a degenerating spiral ensues that leads to diabetes, and nowhere good.

Why, despite all the chatter and hand wringing, are we continuing to get fatter? Who knows. Unless, of course, it has something to do with a toxic blend of predatory profiteering, institutionalized deception, mindboggling gullibility, cultural obsolescence, reductionism ad absurdum, and a seemingly endless capacity for shameless hypocrisy. So, who knows, other than that, is what I mean.

We may all acknowledge, with the great pride warranted, that fighting childhood obesity and simultaneously marketing multicolored marshmallows and toaster pastries to our children as part of their complete breakfast is an impressive feat of cultural legerdemain.

Folks, we are reaping just what we sow. Fixing epidemic obesity will not, by any means, be easy. If someone has told you otherwise, I suggest you check your wrist and back pocket, because they have likely lifted your watch and wallet, too.

It won't be easy, but it's no great mystery either. We are not clueless about the basic care and feeding of Homo sapiens. Our failure to turn what we know into what we routinely do is not a product of ignorance, but of inveterate resistance. Inveterate resistance born, presumably, of preternaturally thick skulls. We don't really want to know what we know, and we clearly don't want to do much of anything about it.

So our middles are getting thicker, but not to worry; it's all good. They will better match our heads that way.


David L. Katz, MD, MPH, FACPM, FACP maintains that anyone appraising our culture with even vague honesty is almost certain to wind up in a state of perennial nausea. This phenomenon, while not entirely pleasant, does at least confer some measure of defense against obesity.

Author, Disease Proof ("Listen to my son, he's a doctor!" - Dr. Katz' Mother)

Co-parent, ("I can't talk, my mouth is full!" - Dr. Katz)