Land of the fat

Obesity kills 300,000 people a year in America and is the nation's number-one health hazard. Nowhere is this more true than in Mississippi, where food is cheap and exercise unheard of. Matthew Engel visits the heaviest state of a country that is in danger of busting the scales.

Thursday May 2, 2002
The Guardian

It is one of those silent, brooding mornings in a small Dixie town: already hot and humid just after breakfast-time. There is hardly anything here: just a shop, a filling station and a building with a sign saying Total Fitness, though judging by the rusty chain holding the padlock, that has been closed for a long time. There is hardly anyone about either, and they all move slowly: partly because of the heat, partly because they cannot do otherwise. The average weight of the population appears to be around 20 stone. The name of the place, without a word of a lie, is Chunky, Mississippi.

The US has what has widely been described as an obesity epidemic. And Mississippi is the sickest state in the country. More than 62% of its population meet the accepted definition of being overweight, and 24% are officially obese. These figures are certain to be understated because the information comes mainly from phone surveys, and people tend to lie about their weight. But they always did lie; and still the rates have almost doubled in a decade.

Obesity is now said to be responsible for 300,000 American deaths every year - that's 100 times the number killed on September 11 - and it eats up 12% of all the US's healthcare costs: $100bn a year. Mortality increases by up to a quarter for the overweight, and can double for the obese, never mind those described as "supermorbidly obese". Last month, the US tax authority formally recognised obesity as a disease, allowing patients to claim for the cost of prescribed weight-loss treatments. This disease causes heart attacks, strokes and diabetes. As a health problem, it now far outstrips drinking and smoking.

Manhattan and San Francisco may be full of joggers and rich young things rushing to see their personal trainers before dawn. But any European who penetrates the very different Bible-bullets-and-Big Mac America that exists outside these sophisticated cities will spot the symptoms at once. Many of the people there no longer walk; they waddle. Most of the time they prefer to sit. In Mississippi, 33% of adults take no exercise at all.

The other half of the equation can be seen in any restaurant. The word "sandwich" conveys something more like a large loaf: Americans believe they are being swindled if they are not served portions that would disgust most Europeans. A middle-aged Englishman, mildly concerned about his paunch, can look around the room and feel like Gulliver in Brobdingnag: a midget amid a race of giants.

It would be fitting if Chunky were the true Fat City: Ground Zero of this catastrophe. But there are plenty of other contenders in Mississippi alone. The problem is known to be acute in the river delta, where mechanisation took away the harsh old jobs in the cotton fields. The Overeaters Anonymous class in Tupelo has a valid claim for the title of America's corpulence capital, as does the office handing out food stamps to welfare claimants in Meridian (next to Sam's Fashion, which sells 58-inch waist trousers).

The clientele on the slot machines in the Starlight Lounge of the casino on the Choctaw reservation in Neshoba County are fairly substantial, though they are outweighed by the customers of the Piggly Wiggly supermarket next door, where the Choctaw shop. There may be nowhere at all to match aisle 10 in Piggly Wiggly's, between the Brown Cow ice-cream ("swirled with thick, rich chocolate syrup") and the giant-sized packs of bacon-and- cheddar fries.

The worst of this will not be in the rich white suburbs. Mississippi is used to coming first - or last - in national league tables. Usually, it is ranked number one among the states for poverty, and 50th for education. Both are relevant. But Mississippi is not unique. Its obesity figures are only slightly worse than several other states: not only in the south (Colorado, with its mountain air and bike paths, is at the other extreme, at about 13%). The worst-affected community of all is said to be the Pima Indian tribe of Arizona. The US is not even the most obese nation on earth: in parts of the South Pacific, such as Western Samoa and Nauru, the slender have been driven almost to extinction.

Dr Alan Penman, an epidemiologist with the Mississippi department of health, prefers not to use the word epidemic. "That implies something that comes and goes," he says. "What we have here are normal adaptations to the kind of environment we now live in. It's Darwinian. Everyone is at risk, if not actually affected, because we have created what some people have called an obesogenic environment. The Americans have done it very well, better than anyone. And it's not going to go away for generations."

Chief among the probable causes of the crisis is prosperity. The old correlation between poverty and starvation is no longer relevant in the US, a country where it is exceptionally cheap and easy to eat large quantities of bad food. Indeed, it can be difficult to do anything else: supermarkets have a far less sophisticated selection than in the UK, especially in poor areas, and a huge proportion of space devoted solely to snacks. American consumers are bombarded with far less of even thespurious health information found on British packets ("85% fat-free" - ie 15% fat). The price of a double whopper with cheese is coming down, though its calorific value (1,060) is not.

Black women aged 45-54 (56% of whom are obese in Mississippi) are the worst affected of all. But the epidemic, or Darwinian adaptation, affects all sections of society: black and white, male and female, rich and poor, old and - most worryingly - young. Obesity rates among American children are rocketing, and both the US and the UK have recently observed the first childhood cases of type two diabetes, a disease formerly confined to the rotund middle-aged.

Penman comes from Ayr, and recognises in Mississippians some of the characteristics that have given the Scots similar, if milder problems: a taste for fried food, and a distaste for exercise. Many of the causes are endemic to all western societies: sedentary jobs, irregular mealtimes, couch-potato children. But he is confident that things will never get as bad in Britain as they are in the US.

For a start, in some parts of the country, Americans have eliminated not merely the need to walk, but even the possibility of it. "I'd love to be able to walk to the store, pick up some milk and come home again, but our towns don't really allow that," laments Mary Gilmore, a dietician in Meridian. The distances are too great, the pavements non-existent. In the sprawling suburbs and small towns, public transport is often as rare as in an English village. In any case, it is almost impossible to carry the milk: it usually comes in gallon containers (a US gallon is four-fifths of a UK gallon). In a country where the cost of packaging exceeds the cost of the food, buying any other way is far more expensive.

This does not apply only to milk. Gilmore runs classes to encourage people not to diet - which rarely works in the long term - but to change their lifestyles. Her students, many of them now disarmingly svelte, were reminiscing for me about how they became fat. "One of those bars is a dollar and six cents, but a six-pack is only two-fifty," one of them, Judy, was saying. "I like a lot for my money." Unfortunately, I had missed the start of the sentence. "Frozen Snickers," she repeated. "Go try."

Frozen Snickers are not particularly Mississippian, but other items are: fried catfish, crawfish, shrimp and oysters; even fried green tomatoes and fried dill pickles (rather tasty, actually). Plus lashings of sweet iced tea ("the house wine of the south"). Even the local attachment to religion is unhelpful. "Church puts a lot of weight on folks," according to Candace, another class member. "There are regular social occasions, and food is always there, and you don't want to offend people by refusing what they've brought. We have a lot of family reunions, too. We even overeat at funerals. There are casseroles, and people put in cream of chicken soup, tons of Velveeta cheese, bacon and ..."

"Hush, Candace," said Bill, across the room. "You're making me hungry."

The attraction of Gilmore's class is that she does not rule out casseroles or even Frozen Snickers. She advises regular sit-down meals - which happen less and less in societies where mothers have full-time jobs - and regular exercise, however light. She calls her programme "10,000 Steps", the number she thinks people should take a day, and hands out pedometers to help them keep count. Some of her clients have dropped as low as 1,200: sub-sedentary, she calls them. Most people must use 300 just going to the toilet and back.

In Mississippi, there is also the climate, which for half the year is too enervating to make any activity attractive. Before air conditioning, it was as easy for kids to play outside as in; now it is easier to justify their inactivity.

The state is only just starting to wake up to the problem: a bill to reintroduce compulsory PE in schools failed in the legislature this year, when schools complained that they did not have the time or resources to implement it. The popularity of American football means many parents are happy to see their boys gain weight, even if it is fat, not muscle. And the grandmothers are pushing in the same direction: many of them remember when poverty in Mississippi really did mean starvation.

Dr Ed Thompson, the state health officer, feels a sense of frustration at dealing with a disease that cannot be cured by normal medical means. "We've protected society from many communicable diseases. But we're now dealing with lifestyle decisions," he said. "We can immunise you, we can keep malarial mosquitoes away from you, we can give you clean water. But we can't exercise for you. In the end, the individual has to make the choices. We want to make it the norm to have a healthy body weight. How do we achieve that? As soon as I figure out how to achieve world peace, I'll tell you."

"You can't just put out messages saying, 'Eat Less. Exercise More,' " says Penman. "That only works for the worried well. You have to create an environment where people make those choices without thinking."

But as things stand, everything in American society is heading in the opposite direction. Britain is to some extent protected by its lack of space and stern planning laws. American developers, meanwhile, can put up houses however and wherever they want, and communities are becoming ever more car-oriented. What's more, the fast-food industry is going through what USA Today calls "drive-thru mania", with 80% of the growth going in sales to customers who have cut out, of their alleged 10,000 a day, the 50-odd steps to get from the car park to the counter and back. This applies even to such unlikely companies as Starbucks and 7-Eleven. "I don't like getting out of my car," a Californian single mother told the newspaper. "Who does?"

The health professionals are doing little to buck the trend. Gilmore's class takes place in a hospital building with a drive-through pharmacy. The Mississippi health department, where Thompson and Penman work, has just moved into a new four-storey office block. Except in emergencies, it is effectively impossible to use the stairs.

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