1. Mason, Diana J. PhD, RN, FAAN, AJN Editor-in-Chief

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Iam, technically speaking, obese, although I think of myself as overweight. But I would have to lose 40 lbs. to be in the "overweight" category as determined by body mass index.


I've engaged in the weight war since childhood. In my teens I was prescribed thyroid medication and amphetamines. I've tried diets, acupuncture, hypnosis. Nothing has worked for more than a few months. I inherited a genetic predisposition to gaining weight, and carried on a familial tradition of cleaning the plate when eating. These factors, combined with too little regular exercise, conspired against me, congealed like so much adipose tissue.


I am one of a growing number of people struggling with this question. In 2002, 65% of U.S. adults were overweight or obese, as Judi Daniels points out in an article on page 40. I finally decided to shift my concern from my weight to my health. I quit smoking almost 20 years ago. I walk between 30 and 50 minutes most days. I don't eat junk food, and I follow a quasi-vegetarian diet. I'm still overweight, but I've stopped the annual creep of pounds, and my latest lipid profile was the best it's ever been. I lose and gain small amounts, depending on my stress level and how much I eat, and these are intertwined.


Is this good enough? If not, to what lengths should I go to lose weight? Bariatric surgery? Purging? Drug therapy? Fasting? Yo-yoing (weight cycling) may be more damaging to cardiovascular and kidney health than remaining overweight. If I'm living an otherwise healthful life, is my weight a problem? And if it is, how much of one?


We're in danger of promoting weight loss at the expense of healthful living. The jury is still out about what degree of excess weight is harmful and how it's harmful. Olshansky and colleagues presented an analysis in the March 17, 2005, issue of the New England Journal of Medicine showing what they call the "life-shortening effects" of obesity on Americans. But in a controversial study in the April 20, 2005, issue of the Journal of the American Medical Association, Flegal and colleagues reported that obesity was linked with more "excess deaths" than normal weight was, but overweight was not. In fact, DiMaria pointed out in the March 2005 AJN that an ideal body weight may be higher in older adults, noting that a bit of padding may protect against fractures. We clearly need more focused research to determine when and for whom "excess" weight is a problem.

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As a society we view fat as a failure, a character flaw, rather than as a complex problem with psychological, genetic, physiologic, and social components. We're obsessed with weight as well as food: we've declared war on obesity yet have devoted an entire television channel to food. And there are class disparities in this paradox. The poor usually pay more for most foods than the middle class do. High-fat, high-carbohydrate foods are more available in poorer communities than the organic foods available in upscale neighborhoods.


Social factors shape exercise patterns (do you drive to work or walk?), eating patterns (do you eat for pleasure or survival?), diet (what foods are available in schools and work-places?), and notions of ideal body size (I long for the days of Peter Paul Rubens, who painted women who look like me).


Weight gain and loss are complex phenomena. I have no doubt that helping people to lose weight when they need to will, ultimately, require a multi-pronged approach, with attention to diet, eating behaviors, exercise, and public policy. Let's focus on promoting health as the answer-not only to weight loss but to reducing the incidence of chronic kidney disease, cardiovascular disease, and a host of other conditions.


I continue to be mindful of my eating, because I believe that weight loss will be of benefit, but I won't take drugs to lose it and I won't embark on wacky diets. Life is short, and so I think of Rubens when I eat that chocolate truffle, the one I eat-slowly-after walking my dog.