Retrospective #147:Obesity is a Disease (for billing purposes)

The New York Times article begins, “The American Medical Association has officially designated obesity as a disease…” This ties in nicely with my last two columns, #146, “Medicare to Pay for Obesity Counseling” and #145, “Gastric Bypass vs. Medical Therapy,” and the next, #148, “Obesity, a Condition of Genetic Susceptibility?”

The AMA call was a tough one for a variety of reasons, not least of which is that there is no general agreement in the scientific community on the definition of “disease.” The Times piece explains, “Those arguing against it [the designation of obesity as a disease] say that there are no specific symptoms associated with it, and that it is more of a risk factor for other conditions than a disease in its own right.” In making the designation, the AMA at their convention overrode a recommendation against doing so by a committee that had studied the matter for a year.

The committee said that “obesity should not be considered a disease mainly because the measure usually used to define obesity, the body mass index (BMI), is simplistic and flawed.” The committee argued that “some people with a BMI above the level that usually defines obesity are perfectly healthy while others below it can have dangerous levels of body fat and metabolic problems associated with obesity.” The committee wrote, “Given the existing limitations on BMI to diagnose obesity in clinical practice, it is unclear that recognizing obesity as a disease, as opposed to a ‘condition’ or ‘disorder,’ will result in improved health outcomes.”

According to an article in Forbes by Chris Conover, the AMA finessed the BMI business by “simply defining obesity as an excess of body fat sufficiently large to cause reduced health and longevity.” According to Conover, “they answered the question of ‘should we consider obesity a disease’ largely on utilitarian grounds – that the social benefits of doing so will outweigh the costs.” Conover then went on to brilliantly demolish that argument.

Conover said, “the AMA is (late) to the party.” The National Institutes of Health declared in 1985 that “obesity is a serious health condition that leads to increased morbidity and mortality.” And the National Heart, Lung and Blood Institute commented in 1995 that “obesity is a multifactorial chronic disease developing from multiple interactive influences of numerous factors.” And he cites the Surgeon General’s 2001 Call to Action to Prevent and Decrease Overweight and Obesity. And Michelle Obama’s 2009 Taskforce on Childhood Obesity. Even the IRS considered obesity to be a disease, and Medicaid jumped on the bandwagon in 2010. Medicare has too, for counseling and surgery, but not for reimbursement for weight loss drugs. Why then is the AMA defining obesity as a disease now?

If we needed one, The Times gives us a clue to a motive for the AMA action. One advocate commented, “I think you will probably see from this, physicians taking obesity more seriously, counseling their patients about it.” And it noted, “…it could help improve reimbursement for obesity drugs, surgery and counseling. Two new obesity drugs – Qsymia…and Belviq…have entered the market in the last year,” and “Qsymia has not sold well for a variety of reasons, including poor reimbursement…”

At the Huffington Post, self-described policy wonk and blogger Larry Cohen enthusiastically huffed, “After the AMA announcement, some members of Congress introduced a bill to expand Medicare reimbursements for weight-loss drugs and weight-reduction treatment.” The Washington lobbyists jumped in exaltation.

And then The Times piece cracks the door open just a bit with, “Some doctors say that people do not have full control over their weight,” and “that ‘medicalizing’ obesity by declaring it a disease would define one-third of American as being ill and could lead to more reliance on costly drugs and surgery rather than lifestyle changes. But, if the treatment is merely treating a symptom (obesity), rather than the underlying disease, doesn’t that solidify a wrong treatment modality for a non-existent disease? The AMA finessed that too by saying that obesity was a “multimetabolic and hormonal disease state” that leads to unfavorable outcomes like type 2 diabetes and CVD.”

Neither The Times nor the AMA subscribes to Gary Taubes’s Alternative Hypothesis that INSULIN RESISTANCE, the metabolic disregulation that characterizes Type 2 diabetes, is what leads to fat accumulation. (obesity).

Retrospective #146: Medicare to Pay for Obesity Counseling

“Medicare to Pay for Obesity Counseling in the Name of Prevention,” trumpeted DiabetesinControl.com. What a boon for physicians! And what a mixed blessing for their patients! Medicare finally recognized that obesity prevention in the form of counseling, as public health policy, might be as effective as costly gastric bypass surgery. Reducing obesity through “intensive medical nutrition therapy…could produce similar results,” it concluded. But only if your primary care physician “supervised” its administration. This sounds to me like it’s all about the billing.

Medicare reached this conclusion because “It’s almost impossible for physicians to take care of everything. They don’t have the expertise [how true!] or the time” [also true!]. “Seventy-two percent of primary care physicians surveyed…said nobody in their practices had been trained to deal with weight-loss issues.” Yet they [the physicians] say, “unfortunately, those best prepared to provide obesity counseling will not be able to bill directly to do so.”

Why is that? Under the Medicare rules, “those with expertise in the field, such as registered dietitians [?!], are not eligible to bill directly.” Medicare, with perhaps a little lobbying from the AMA, “has limited who is able to bill for those services to primary care physicians, including nurse practitioners, clinical nurse specialists and physician assistants. Medicare will cover services from ‘auxiliary’ providers only if the service is provided in a physician’s office suite and the physician is immediately available to provide assistance and direction.” Yep, it IS all about the billing.

But the consequences for the patient are dire. Registered dietitians and CDE’s, if they follow the training required for certification, are the least qualified persons to provide obesity training, at least to the Pre-diabetic and Type 2 community. This has been my personal experience from attending group counseling for diabetics provided by a CDE/RN at a local health care facility, and years ago with a registered dietitian, plus more recently with a CDE.

Years ago, my doctor employed a registered dietitian in his “office suite.” I remember well her advice to “Eat a ‘balanced’ diet and exercise.” The truth is that she was as ignorant as my doc about the effect on a Type 2 diabetic of eating a “balanced” diet of from 40% to 60% carbs. But my meter provided plenty of feedback, all of it negative.

Forty-five to sixty-five percent carbs is the amount recommended by the Institute of Medicine for everyone in the 2010 Dietary Guidelines for Americans (Table 2-4, pg. 15). The USDA’s Nutrition Facts panel on processed food packaging is likewise a one-size-fits-all formula. Carbohydrates are 1,200 (60%) of the 2,000 calories in the Standard American Diet (SAD,) for a woman. More for a man. And that, folks, is why Type 2 diabetes is a progressive disease!

My experience with a CDE (employed by a doctor) was the result of a silent auction for a non-profit a few years ago. The bidding started at $20, so I placed the first bid, and it was the only bid. At this point I had been eating Very Low Carb for about 10 years. I had lost 170 pounds and had eliminated virtually all my oral diabetes meds. My blood glucose was normal, my blood pressure (on the same meds) had dropped dramatically, and my blood lipids (both HDL and triglycerides) had totally turned around. I no longer had Metabolic Syndrome or detectible hypertension (with meds) or Type 2 diabetes as long as I refrained from eating carbohydrates.

Okay, those conditional statements are caveats, but that is a price I was and am willing to pay for the complete abatement of my symptoms. In doing so I am now at much lower risk of all the Diseases of Civilization to which I was exposed before I began this Way of Eating. It was a rough session, for the CDE, but she toughed it out. In retrospect, it wasn’t very nice of me to do that to her, but maybe it will pay off. Maybe she will have an epiphany.

So “save your money,” so to speak, if counseling is voluntary as it is with Medicare, or just ignore the advice if obesity counseling, also at government expense, is required by the NHS. Your health will be better served if you listen to your meter and avoid any “one-size-fits-all” diet plan.

Retrospective #145: Gastric Bypass vs. Medical Therapy

Recently, my Medscape alert brought me a story on “Gastric Bypass vs. Conventional Medical Therapy for Metabolic Syndrome.” I read it, and the full paper in JAMA, and my reaction was that it would be funny if it weren’t so very sad. This study used a “2-group unblinded randomized trial” and is a perfect example of how bloody blinkered the medical community is to the treatment of Metabolic Syndrome and its associated co-morbidities.

This narrow mindedness is best demonstrated by the first bold heading in the abstract: “IMPORTANCE: Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown.” Unknown!!! Let’s face it. This naïve statement is just a set-up to obfuscate and camouflage the true purpose of the entire enterprise: to promote gastric-bypass surgery in “mild to moderately obese patients with Type 2 diabetes.” Generally gastric bypass is reserved for the morbidly obese patient (BMIs ≥ 35). The growing number of gastric bypass surgeons, however, requires that there be more “eligible” patients. And the sooner the better, before the unfortunate side effects such as “dumping episodes” and a higher suicide rate are better known. 

Controlling glycemia, blood pressure, and cholesterol are certainly important for patients with diabetes. How best to achieve these multiple goals (collectively known as Metabolic Syndrome), is certainly, however, NOT UNKNOWN. It has been documented innumerable times in countless papers published in the peer reviewed medical literature. The problem is that control is NOT ACHIEVED with “medications for hyperglycemia, hypertension and dyslipidemia (that) were prescribed according to protocol” nor with “surgical techniques that were standardized,” to quote from the specific “interventions” utilized in this trial. Control is achieved by what type of food you eat.

This study had a “lifestyle modification” component modeled on recent “successful clinical trials, they said, particularly the “Diabetes Prevention Program” and the “Look AHEAD Protocol.” The interventions in those trials were to lose 7% of body weight and to exercise 150 minutes (!) a week. The Look AHEAD Protocol also examined whether weight loss reduced the risk of heart attacks and strokes in obese Type 2 diabetics. It did not.

Maybe (Is my sarcasm too thick?) the problem with these studies is what they have in common- a “healthy low-calorie, low-fat diet” that fails to lower blood glucose enough to reduce the risk of diabetic complications, including heart disease. The lifestyle intervention protocol in this trial was similar for participants in both treatment groups.

In the Gastric Bypass study protocol, “Portion controlled diets using meal replacements, structured menus, and calorie counting…encouraged to help participants stay within calorie limits.” “Both groups met regularly with a trained interventionist to discuss strategies for facilitating weight management and increasing physical activity. Topics included self-monitoring, stimulus control, problem solving, social support, cognitive behavior modification, recipe modification, eating away from home, and relapse prevention.”

Maybe I am being too hard on these gastric bypass surgeons. Study participants were, after all, a “failed” cohort. Participants had diabetes for an average of 9.0 years, had a mean BMI of 34.6, and a mean A1c of 9.6%, in spite of medications to control diabetes and cardiovascular disease risk factors (statins). Perhaps I should ignore the fact that the Principal Investigator, or PI, who created the study concept and design, drafted the manuscript, and provided study supervision, received funding for the study from Covidien, a leading manufacturer of surgical devices, as well as serving on the medical advisory boards of Novo Nordisk, USGI, and Medica. Eight other co-authors, all doctors and support staff, also reported receiving grant support from Covidien, including one who received salary support for what, in small print, is called, unabashedly, “The Diabetes Surgery Study.” 

I can ignore these funding facts, just as they ignore an effective dietary therapy for hyperglycemia (carbohydrate intolerance). To achieve control, you need to eat fewer carbs. As your weight drops your blood pressure and cholesterol will improve too. Your weight is under your control because what you eat is under your control.

Retrospective #144: Diabetes and Dementia

The “Background” in the Abstract of this August 2013 piece in The Lancet states: “Although patients with Type 2 diabetes are twice as likely to develop dementia as those without this disease, prediction of who has the highest future risk is difficult. We therefore created and validated a practical summary risk score that can be used to provide an estimate of the 10-year dementia risk for individuals with Type 2 diabetes.” Diabetes in Control, a digest for medical doctors to which I subscribe, picked it up. Have I got your attention yet? Well, it gets much scarier.

The researchers were from the University Medical Center Utrecht, Netherlands, the University of Chicago, the University of Washington, and Kaiser Permanente. In 2013 Kaiser Permanente was the largest managed care organization in the U. S., with almost 9 million health plan members, 15k doctors, 170k employees, and $50 billion in annual revenues. Kaiser Permanente, the National Institute of Health, and Fulbright funded the study.

The researchers used data from patients with Type 2 diabetes, aged ≥60 years, with 10 years of follow-up. The risk factors in their analysis that were “most strongly predictive of dementia” were “microvascular disease, diabetic foot, cerebrovascular disease, cardiovascular disease, acute metabolic events, depression, age, and education.”

The outcome of their risk analysis? “The prediction of 10-year dementia risk in patients with Type 2 diabetes mellitus “shows a 5.3% risk for the lowest score and 73.3% for the highest score. The Diabetes in Control piece states, “According to the authors of this study, those in the higher risk category were 37 times more likely to develop dementia than those in the lowest risk category.”

How do they plan to use this information? You’ll love this. They say, “The risk score can be used to increase vigilance for cognitive deterioration and for selection of high-risk patients for participation in clinical trials” (my emphasis). And that’s it! In other words, they watch as you develop dementia, and then perhaps suggest that you sign up for a clinical trial to test another drug to treat your cognitive deterioration. Isn’t that just dandy!

Of course, there is another way. Remember, the researchers who created and tested this risk analysis prediction tool used “data from approximately 30,000 Type 2 diabetic patients aged 60 and greater over a 10-year interval.” These diabetics were presumably being advised to eat a “one-size-fits-all” low-fat, high-carb, restricted-calorie diet, with lots of “healthy fruits and vegetables” (all carbohydrates) with minimum saturated fat and dietary cholesterol.

Most were probably also medicated for hypertension (high blood pressure) and for high cholesterol with statins.

Further, the treatment standard that the clinicians were using was undoubtedly the one supported by the current “Standards of Medical Care in Diabetes” published annually in Diabetes Care, the Journal of the American Diabetes Association. That means that your physician will be safe-guarded from medical liability to simply advise you that your Type 2 diabetes is “under control.” He will not inform you that your elevated blood glucose levels, as allowed by this standard, are progressively damaging your blood vessels, organs and endocrine system.

If you leave the care of your Type 2 diabetes in the hands of your physician, this is what will happen to you: As he observes your A1c rise, he or she will prescribe higher doses and more medications until you are maxed out, and then possibly switch you to injected insulin. Repeat for your elevated cholesterol and high blood pressure.

And when you are unable to lose weight and keep it off on a low-fat, high-carb diet, as he makes a note in your file that the “patient was non-compliant,” you will be reminded again to “eat less and exercise more.”

Don’t be a member of this treatment cohort. Take charge of your own health. Do not accept an A1c of ≤7.0% as “in control.” At this level, your heart attack risk is doubled. Eat a diet that is low in carbohydrates; better yet, VERY low. Don’t sweat the saturated fat and dietary cholesterol. Your body will love it. And so will your doctor. He or she will be pleasantly perplexed with your lab results and weight loss, and will almost certainly lower your meds, and then tell you to “just keep on doing what you’re doing.” That’s an outcome you can both happily live with.

Retrospective #143: Fruit Consumption & Diabetes – a Theater of the Absurd Plot

No sooner had I posted #138 in 2013, “Fruit, the 3^rd Rail for Prospective Low Carbers,” when my Medscape Alert (not “The Onion”) brought me an absurdist piece: “Consumption of Certain Fruits Linked to Lower Diabetes Risk.” I was dumbfounded. How could the consumption of any food, whose only macronutrient is simple sugars, “lower diabetes risk”? It just made no sense. Am I living in an incomprehensively illogical world? A world without meaning? Has the respected research community abandoned rational thinking, I asked? I had to read the piece.

The report was from the Department of Nutrition, Harvard School of Public Health, and appeared as an online article in BMJ, the British Medical Journal. The Medscape writer wrote, “Increasing fruit consumption has been recommended for the primary prevention of many chronic diseases, including Type 2 diabetes, although epidemiologic studies have generated somewhat mixed results regarding the link with risk of Type 2 diabetes.”

The impetus for the study writer’s hypothesis appears to be, “The inconsistency among these studies may be explained by differences in types of fruits consumed in different study populations as well as difference in participants' characteristics, study design, and assessment methods, although a meta-analysis did not show that the associations differed by sex, study design, or location." Okay, all epidemiological studies inherently have many confounding factors and biases, but the hypothesis proposed to address these factors is, IMHO, also inherently flawed. Just because “differences in types of fruits consumed” was not previously studied, does not lead to the conclusion that the types of fruit consumed are a differentiating criterion. True, the authors cache their hypothesis carefully in the word “may,” but that did not similarly constrain the report’s conclusions, or the gushing headlines.

The authors’ conclusion: "Overall, these results support recommendations on increasing consumption of a variety of whole fruits, especially blueberries, grapes, and apples, as a measure for diabetes prevention." Unbelievable!

The article received funding from the National Institutes of Health and was published on August 29, 2013. It immediately was picked up and ‘broadcast’ in such places as The Guardian, Science Daily, Medical News Today, The Huffington Post, the Daily News, Today.com and FoxNews.com. The lede in the e! Science News piece was, “Eating more whole fruits, particularly blueberries, grapes, and apples, was significantly associated with a lower risk of Type 2 diabetes, according to a new study led by Harvard School of Public Health (HSPH) researchers.” WOW!

Sadly, and invariably, the headline and the lede is all that the mass media market will pick up: “Eat more fruit to lower your risk of diabetes.” I feel at times like a character in an absurdist plot, “facing the chaos of a world that science and logic have abandoned,” to borrow from a Wikipedia passage describing Theatre of the Absurd.

The absurdity is further confounded by the inherent contradiction of the perfunctory conflicts of interest disclaimer: “The study received funding from the National Institutes of Health. The authors have disclosed no relevant financial relationships.” In other words, fruit growers didn’t pay them to say that “eating more whole fruits...was significantly associated with lower risk of Type 2 diabetes.” But the National Institutes of Health did! No conflict of interest there! We taxpayers paid the costs in furtherance of the government’s goals to promote “healthy” fruits and vegetables and avoid animal-based “unhealthy” saturated fats and dietary cholesterol.

Note also that the authors were careful to say that the results were “linked” to the outcomes. The conclusions of all such epidemiological “studies” show only an association, not a causal relationship, and a weak one at that. The confounding factors, including multiple biases assumed, are expressly discussed near the end of such “studies,” inevitably making the conclusions subjective. The final paragraph of such full “studies” then invariably acknowledges that the conclusions are inconclusive and require “further study,” preparing the ground, in the name of “science,” for another grant application to pay for another round of so-called “research.” Call me cynical, if you want, but to me this ongoing charade is phantasmagorical and surreal, if not downright Machiavellian.

Oh, well, at least you can be comforted to know that your humble blogger is not paid for his opinions.

Retrospective #142: “I’m Sorry…” Confessions of a Former Weight Loss Consultant

“An Open Apology to All of My Weight Loss Clients,” sent my way by a friend, caught my attention. It was on the website of Iris Higgins, a “certified hypnotherapist, past life regression specialist, and women’s health coach.”

Ms. Higgins opens with, “I worked at a popular weight loss company for three years…” She then confesses, “I’m sorry that I put you on a 1,200 calorie diet and told you that was healthy.” Now she really had my attention. I currently eat a 1,200 calorie a day diet, and I weigh probably twice what she and most of her clients did, and I’m very healthy (besides being a Type 2 diabetic for 33 years). Is she going to tell her former clients that just eating 1,200 calories a day is unhealthy? Well, she does, but as my readers know, a calorie is not a calorie because…

All calories are not alike. The body metabolizes foods differently, according to their macronutrient composition. A carbohydrate calorie is not processed the same as a protein calorie or a fat calorie. On this, you must be clear.

Higgins’ confession, though, is sincere. And here is where she gets to her point: “that you’ve been played.” “And that’s why I’m sorry,” she says, “because I’ve been played for years…” “And it wasn’t just the company [her employer] feeding them [lies] to me. It was the doctors and registered dietitians on the medical advisory board. It was the media and magazines confirming what I was telling my clients.”

She sold her clients food that helped them “lose weight and then gain it back, so that you thought we were the solution and you were the failure,” she wrote. “You became a repeat client, and we kept you in the game.”

Ms. Higgins’ main thrust is that most of her clients were not really overweight. Recall what we learned in Retrospective 141: In 1997 the World Health Organization redefined obesity with the result that many of her clients obsessed over losing a few pounds to satisfy their mother or some other societal pressure to conform to an artificially created norm of what is considered a “healthy” weight. Amen to that! BMI be damned, I say.

My main disappointment with this confession, however, is that Ms. Higgins failed to understand the cause for the yo-yo weight swings of her clients. “When,” she asks, “did we become ‘professional dieters.’”? “I’m sorry because I get it now,” she says wrongly. “If you’re trying to starve your body because you’re eating fewer calories than it needs, of course it’s going to fight back.” Of course it will, but she fails to see why. Calories are not the problem.

The macronutrient composition of the diet is the problem. What your body does with the calories that you eat – burn them or store them – is the issue. The quality of the calories you eat is the issue. And the quantity of low-quality processed carbohydrate “foods” that we eat is the reason we gain weight. Avoiding these processed and manufactured “foods” is the solution.

At the end of her “confession,” Ms. Higgins does share some good advice. She concludes, “Just eat food. Eat real food, be active, and live your life. Forget all the diet and weight loss nonsense. It’s really just that. Nonsense.” 

Of course, if you’re seriously overweight (obese or morbidly obese), and you have health issues (hypertension and/or ‘high cholesterol,’ you can lose weight naturally by following Ms. Higgins’ “real food” advice, tweaked only to eat many fewer carbohydrates, moderate protein and high fat, even just 1,200 calories a day.

By changing only the type of food you eat, you will lose weight without stress and without hunger. Real food, unprocessed and unmanufactured, is higher in bio-available nutrient value than the refined “foods” that dominate the boxes and bags on supermarket shelves. And they have no added sugars, and fewer “natural sugars” and carbs.

I make no brief for or against “hypnotherapy, past life regression analysis or rediscovering the magic in your life.” They may indeed be good pursuits. But if you need to lose weight (only if you really need to), you might try a LCHF Way of Eating. It’s a way to eat 1,200 nutrient dense calories a day and be healthy without hunger. The rest of the energy your body needs will come from your fat stores. Don’t get played!

Retrospective #141: “…the ultimate oxymoron: diet food”

An article by Jacques Peretti in “The Guardian,” brought to my attention by now defunct blogger Beth Mazur, used this construct to describe one aspect of the symbiosis that has developed in the food industry in the last sixty years. It’s a provocative piece – well reasoned – and a worthwhile read, especially if your BMI is in the range of 25 to 27.

Peretti begins, “When you walk into a supermarket, what do you see? Walls of highly calorific, intensely processed food, tweaked by chemicals for maximum "mouth feel" and "repeat appeal" (addictiveness). This is what most people…actually eat. Pure science on a plate. The food, in short, that is making the planet fat.

Then, “And next to this? Row upon row of low-fat, light, lean, diet, zero, low-carb, low-cal, sugar-free, "healthy" options, marketed to the very people made fat by the previous aisle and now desperate to lose weight. We think of obesity and dieting as polar opposites, but in fact, there is a deep, symbiotic relationship between the two.”

Diet food then is an oxymoron because it is something you eat (to nourish your body) but which is intended for you to lose weight. How did this come about? Peretti explains: “When obesity as a global health issue first came on the radar, the food industry sat up and took notice. Some of the world's food giants opted to do something both extraordinary and stunningly obvious: they decided to make money from obesity, by buying into the diet industry.”

In Peretti’s words, they “squared the seemingly impossible circle. And we bought it. Highly processed diet meals emerged, often with more sugar in them than the originals, but marketed for weight loss, and here is the key get-out clause, "as part of a calorie-controlled diet". “You can even buy a diet Black Forest gateau if want.”

We got fat by eating high calorie, highly processed (carbohydrate) foods. So, what happened? The result, as we all know: “Government, health experts and, surprisingly, the food industry were brought in to consult on what was to be done. They all agreed that the blame lay with the consumer – fat people needed to go on diets and exercise. We needed to slim down by eating lower calorie (low fat), still highly processed (CARBOHYDRATE) food, but as part of a calorie-controlled diet. The plan didn't work. In the 21st century, people are getting fatter than ever.” How come?

Regular readers here know that what went wrong is that “government, health experts and the food industry” came up with the wrong prescription: The low fat, restricted-calorie diet of highly processed, carbohydrate-loaded foods.

Peretti’s “scenario two,” the first being the food industry’s reaction to obesity, was this: “But, seen purely in terms of profit, the biggest market wasn't just the clinically obese (those people with a BMI of 30-plus), whose condition creates genuine health concerns, but the billions of ordinary people worldwide who are just a little overweight, and do not consider their weight to be a significant health problem.” “That was all about to change,” he said.

“A key turning point was 3 June 1997. On this date the World Health Organisation (WHO) convened an expert committee in Geneva that created a report. The WHO report re-defined obesity: the cut-off point for being overweight went from a BMI of 27 to a BMI of 25. This change wasn’t based on any scientific evidence at all. The authors essentially looked at the data and just arbitrarily decided to take the desirable weight for people who were aged 25 and apply it to everyone. Nevertheless, overnight, millions of people around the globe would shift from the "normal" to the "overweight" category.

The people who funded the WHO report were drug companies. And did they ever ask the authors to push any specific agenda, Peretti asked? "Not at all," they replied. It wasn’t necessary. The WHO report was all they needed.

Peretti concludes with this: “There now exist two clear and separate markets. One is the overweight, many of whom go on endless diets, losing and then regaining the weight, and providing a constant revenue stream for both the food industry and the diet industry throughout their lives. The other market is the genuinely obese, who are being cut adrift from society, having been failed by health initiative after health initiative from government.”