The Miracle Pill

by Peter Walker

  All this is useful, but still leaves someone who is overweight, whether gauged by BMI, waist size or both, in roughly the same place as before. So, assuming they do not have the time, resources and focus to attempt a Tom Watson–style turnaround, nor access to a Bulgarian health/punishment camp circa 1982, what is the route to better health? The increasingly clear answer from current research is that they should make every effort to become more active, whether in day-to-day life or through exercise, then try to eat a healthy diet and, to an extent, let the weight issues take care of themselves.

  Robert Ross says people should be urged to be active because of the overall impact it will have on their health, and be aware that any reductions in weight will most likely be both slow and require significant physical investment. ‘If you’re doing sixty minutes, five days a week, well, that’s pretty good,’ he says. ‘And if you’re not eating more, will you lose weight? Absolutely. But many overweight and obese adults say, “Yes, I’ll lose weight, but I’ll lose weight slowly. And I wish to lose weight quickly.”

  ‘I understand that sentiment, and if someone wishes to lose weight quickly, 5 per cent to 10 per cent of body weight over the next two to three months, they’re likely going to need to reduce caloric intake along with physical activity to achieve rapid weight loss. That said, how many more decades of information do we need from across the globe, that large weight losses obtained rapidly are rarely sustained? There’s just so much evidence from very well-performed randomised control trials that show substantial weight loss after six and maybe even twelve months, and then there’s a gradual recidivism, an erosion of benefit, such that after a couple of years they’re right back where they started.’

  Part of this, Ross says, is the body’s biological response to sustained energy deficits: ‘But far more important for the average adult is the recognition that reducing caloric intake substantially, trying to combine that with forty-five or sixty minutes of physical activity most days of the week, is very, very hard to sustain in today’s environment, and most adults can’t do it.’

  People should be reminded that better cardiorespiratory fitness ‘is associated with a substantial reduction in morbidity, disease and mortality risk, regardless of the bathroom scale’, Ross says. ‘That does not, at the same time, suggest that if you lose weight that’s a bad idea. There’s no question that physical activity is an absolutely essential component of the behavioural mix that adults have to do to sustain any meaningful weight loss – and I think the operative word there is sustained. If you lose some weight or reduce your waist circumference as you’re doing that, good for you, but if you don’t, still good for you.’

  This message is now also starting to come from public health professionals, who are on the front line of grappling with the intertwined crises of inactivity and weight. Dr Justin Varney, whom we heard from earlier, was in charge of adult wellbeing at Public Health England, and now runs public health policy in the city of Birmingham.

  ‘One of the things we have suffered from is perhaps the conflation of obesity and inactivity,’ he says. ‘There are lots of other reasons why I’d want you to be physically active, and frankly obesity is not one of them. Physical activity helps you maintain a healthy weight, and it can be an important part of helping you to lose weight. But if you don’t fix your diet, you’re not going to lose weight. It doesn’t work like that. Although I don’t like it, the phrase, “You can’t outrun a Mars Bar” isn’t far off the truth.’42

  Fat and fit

  All this leads us, at last, into the most contentious corner of the activity/weight world, the idea given the catchy, if not entirely satisfactory, title of ‘fat and fit’, or, if you are being slightly more polite, ‘heavy and healthy’. It is an imperfect term in that, as we have seen already, improved physical fitness is worthwhile even if you are overweight, particularly below levels of obesity. The controversy comes if you take the idea a step further: is being overweight and active a better health outcome than lean but immobile? One person who is convinced this is the case is Steven Blair, the veteran South Carolina University academic we encountered earlier in the book, who is among the handful of most eminent and influential researchers into inactivity over the decades.

  Blair has carried out numerous studies which compared mortality rates between physical fitness and weight. Perhaps his most famous paper, published in 1999, assessed nearly 22,000 men of various ages with a treadmill test, and measured their body fat percentage. When the data was analysed from more than 400 deaths over an eight-year follow-up period, Blair and his team found that while lean, unfit men had twice the risk of death as fit men of the same body composition, they were also more at risk than men who were fit and obese.43

  A later study co-authored by Blair assessed the same relationship, but measured not only body fat percentage but also BMI and waist size. This found the latter two measures more significant in bringing a likelihood of early death than fat percentage, but also that fitness (again measured on a treadmill) was even more significant. When the 2,600 participants, all of whom were aged sixty-plus, were split into five bands of descending fitness levels, those in the bottom 20 per cent had four times the risk of death over the twelve-year study period than those in the top quintile. It also found that in the fittest group, even people who were obese, with a BMI of between 30 and 35, had a lower risk of death than those who were normal weight but inactive.44

  Blair is dismissive of his relatively numerous critics, arguing that many studies which come to other conclusions tend to ask participants to assess their own fitness, or base it on self-reported activity levels. ‘You can’t lie to the treadmill,’ he tells me cheerily over the phone. ‘People think I’m absolutely crazy, and we still keep finding the same results, and people attack me and criticise. In the work we have done, obese individuals who are moderately fit and followed over many years are about half as likely to die as normal-weight people who are unfit. I’m not saying we should ignore obesity, and we need to have good strategies for preventing it, and treating it, and all of that. But frankly, it is not nearly as big a public health problem as is inactivity, which leads to low fitness.’

  Blair, who is now eighty, admits he has something of a personal stake in the argument: ‘To be honest with you, I’m a short, bald, kind of fat guy. I’m also very fit. I get 5 million steps a year. But I’ve been physically active my whole life. I set that 5 million steps goal and started it on my seventieth birthday. And I’ve made it every year since then. But it hasn’t made me skinny.’45

  There have been many academic ripostes to Blair’s work. One of the best known was a 2004 paper by Harvard academics which used data from a vast and long-term study co-run by the university into US nurses to track the health outcomes of nearly 120,000 women over an average of twenty-four years. This supported the health risks of both excess weight and inactivity, but found that the death risk for obese and active women was about 30 per cent greater than that for those who had a BMI below 25 but moved little.46

  This is an argument which has run for more than twenty years already, and you could spend a long time poring over the various research papers. And when it comes to everyday life, rather than academic bragging rights, there is an extent to which it is, ultimately, a bit irrelevant. To quote the very straightforward conclusion to the Harvard nurses’ study: ‘Both increased adiposity [excess weight] and reduced physical activity are strong and independent predictors of death.’ Not even Steven Blair would disagree with that, and you would find similar agreement from Robert Ross and Tom Watson, or indeed from more or less anyone who has looked into the intersection between these two gradual, normalised pandemics.

  It is beyond doubt that excess weight brings diminished odds for your future health, all the more so when excess weight moves into clinically defined obesity, whether measured by BMI or waist circumference. This has seemingly been shown, recently and tragically, with coronavirus. So, this chapter is not intended to be a clarion call for people to
completely ignore excess weight as a potential risk. But the hope is that I can persuade at least some people to view weight in a different light: both as a consequence of the lived environment, and also as something which does not have to be a barrier to fitness.

  My own investment in all this is a bit more personal than it was when I began the research. I spent my entire youth very slim, and I was notorious for being able to consume portions of food which bore no apparent relationship to my size. Inevitably, as I have advanced into middle age, what used to definitely be leanness has now become what I like to think of as an average build.

  Average is nonetheless a broad term. As we saw in the last chapter, I’m still officially pretty active, if less so than a few years ago. I also work in the Houses of Parliament, a world of odd hours, frequent drinks events and subsidised canteens. It might not officially count as an obesogenic environment, but new MPs are warned by old-timers to beware of too quickly acquiring what is known as the ‘Westminster kilo’. I was not exempt. At a recent routine asthma check-up at my doctors’ surgery, the nurse looking at my records pointed out that I was in fact two kilos heavier than when last seen, a few years previously.

  I was still unbothered when, during the fitness test at Roehampton University described in the last chapter, I was placed in a machine to measure my body fat percentage. This was a high-tech device called a BodPod, a metal canister looking a bit like a 1950s rendition of an alien spaceship. You sit still inside, and the air displaced by your body is measured, which permits a calculation of how much body mass is lean and how much is fat. The results came a few days later. Below the figure for my VO2 max came the reading for body fat. When I saw it, my disappointment at the reduced VO2 max reading was temporarily forgotten: it said I had 30 per cent body fat. For middle-aged men, a few points above 10 per cent is good, and anything up to 20 per cent is acceptable. But 30 per cent put me in the category of not just overweight, but very much obese.

  I was simultaneously shocked and a bit frightened, but also baffled. The shock came first: so, I thought, despite all that cycling, my insides are distinctly un-lean. I pored over web pages about reducing body fat, and started to plot a post-book regime of running, weights and a Tom Watson–like no-carb diet.

  But most of all I was puzzled. Even with the extra two kilos, my BMI is 22.5, well within the healthy range. My physique looks reasonably lean, clothed or in the bathroom mirror. And for more or less as long as I can remember, I’ve bought trousers with the same waist size, 31 inches (just under 79cm) – Robert Ross’s stated gauge for all being well. What was going on?

  Motivated in part by this confusion, but also perhaps by the much more personal wish for a different answer about my supposed interior obesity, I read academic studies about the accuracy of BodPod measurements. These mainly suggested it is accurate, even if a few papers noted occasional anomalous readings.

  I needed a second opinion. With the coronavirus lockdown now in place, the only way was via the old-fashioned but still much-used skinfold technique. This uses sprung callipers to measure the thickness of an area of pinched-out skin from a few select places around the body, with the combined total of millimetres converted via online charts into a body fat percentage. I duly bought some callipers and followed the instructions of various websites as best I could. A very different answer came back: a total of 15 per cent body fat. Not completely lean, no, but perfectly safe.

  I was even more bewildered. As a last resort, I emailed Robert Ross and explained my predicament. What should I believe, I asked him? Which method was more accurate? It might seem like overkill – not to mention a bit cheeky – to ask one of the world’s leading research experts on excess weight and activity to adjudicate on your own personal obesity issues, but he had seemed very nice on the phone.

  Ross very kindly replied, pointing out that it is a complex area, which depends on multiple factors. The BodPod uses a bespoke algorithm within its software to convert the measurement from the air displacement into a reading, he said: ‘The bottom line is that all field methods of body composition measurement must by design convert some property to whole body fat and/or lean mass scores.’ He sent me a link to a study paper by a colleague, nine densely printed pages explaining the many different ways body composition can be determined, packed with charts, tables and formulae.47 To somewhat oversimplify the study’s message, it says: when it comes to body fat, what answer you receive depends in part on what question you ask.

  I started to get the idea. So, I wrote in another email to Ross, perhaps I should just assume that my consistent, and healthy, waist size indicated all was probably okay, and I could perhaps just worry a bit less? His very concise reply came two minutes later: ‘Amen, Peter.’

  As a final lesson for this chapter, my brief if still unresolved brush with clinical obesity could hardly be more fitting. Yes, it is easy to become complacent about weight, and if your activity level does drop even a bit, as mine had, you can’t rely on your appetite to reduce in turn. But ultimately, if you remain active, it can be easy to get lost in a tangle of different, competing measurements.

  If there is one message that needs to be better and more widely conveyed, it is to dispel the idea that there is not much point trying to become active if you are overweight. Relatively few people can manage the feats of Tom Watson. Many more could benefit from embracing the ethos of Robert Ross: become active, forget about the scales for a bit, and just see what happens.

  Next steps

  Weight and obesity is such a hugely complex and involved subject, but if there’s one message that resonated with me in writing this chapter, it was that of Jean Mayer: if it comes to a choice between permanently reducing your food intake and being more active, the latter is often easier, not to mention more fun.

  7 Your Everyday Life is Dangerous

  If, by any chance, you ever make a speech to a conference populated mainly by public health experts, and at the end they all leap to their feet to applaud, by all means feel satisfied. But don’t get too smug. This could be the phenomenon known as ‘active applause’. This dictates that every speaker receives a standing ovation, not because they are necessarily brilliant, simply as a reminder to the audience to stand up and move around between the presentations. These are the people who have studied the consequences of prolonged sitting more closely than anyone else. Should we pay attention to the fact that they start to get a bit nervy if forced to sit down for more than twenty minutes or so at a time? I think we probably should.

  Like most people, I have been at least generally aware for a while that too much sitting down isn’t the best idea for your health. Sitting, the newspaper feature story headlines proclaim, is the new smoking. As someone who has for more than two decades been in a job, journalism, much of which is done using a chair, I also knew this idea had some personal relevance to me. I was particularly struck by the notion of active applause, explained to me by an academic a few years ago. I must sit down less, I mentally told myself at the time, while not really making any plans as to how this might happen.

  Sitting is, along with Chapter 5’s focus on walking, cycling and stair climbing, probably the way in which the modern world has most carefully conspired against our biological inheritance as active creatures. But, like those, it is also the area where it is often possible to make the most life-enhancing changes. Make no mistake, for all that the ‘new smoking’ headlines overstate the case – unlike tobacco, chairs and sofas don’t kill 1 per cent or so of their users every year1 – there is no doubt that prolonged, particularly uninterrupted sitting, if maintained over decades, does significantly worsen your health odds. While it often coincides with more general inactivity, and many of the health perils cross over between the two, sitting down is a distinct issue and one often not properly understood. It is also more complex than just plonking one’s bum on a seat. Not all types of sitting are the same, and some are definitely worse than others.

  To begin with the terminological basics, sede
ntary behaviour, as distinct from general physical inactivity, describes not just a lack of motion or exertion, but a body that is seated or prone, although not asleep. In clinical terms it is thus possible for someone to be excessively sedentary but not classified as inactive. For example, they might go for a reasonably long run every morning, and then even cycle to work, but sit at a desk for ten hours. Less common but still achievable is to not be deemed sedentary but nonetheless still be classified as inactive, for example a person who stands behind a till in a shop for their job, but moves very little over the course of their day.

  As well as sitting (or lying), being sedentary also means not moving around too much while you do it. The standard academic definition is ‘any waking behaviour characterised by an energy expenditure of less than 1.5 METs while in a sitting, reclining or lying posture’.2 Although 1.5 METs is 50 per cent more energy than that needed for someone’s body to just tick over, it is small enough to cover most seated tasks. One study which tested this out found that even typing or playing video games kept people, on average, below the 1.5 MET level, with the only exception being a Nintendo Wii–type game in which the controller was waved around to play. Standing up, in contrast, immediately nudged people into the territory of 1.6 METs.3

  Sustained sitting down might seem entirely natural to the vast majority of modern people, but it’s worth remembering that the common use of chairs, let alone habitual sedentariness, is a fairly modern development. In a fascinating book which tracks the way the human body has altered with different ways of living over the millennia, Primate Change, the UK academic Vybarr Cregan-Reid makes the point that while chairs have existed for thousands of years, for many centuries they were so rare as to be commonly associated with power or authority – hence the use of ‘chair’ as the highest title in a university.4