Livin' Large

A look at how many of us got this way, what we can do about it, and the weighty issues obesity brings along the way.

Put yourself in Rosie Murrell’s shoes. She says it’s the only way you’ll understand what it’s like. Murrell has endured humiliation and depression, and survived attempts at taking her own life. It all started in kindergarten.

"They weighed everybody when we first started school," she recalls. "That was a horrible day. I got on the scale in front of everybody and weighed 102 pounds. The teacher remarked, 'Girl you're a hundred-plus pounds.' That fueled the little kids. The kids started saying, 'Fatty, fatty, fatty.'"

The timeframe of Murrell's story parallels the dramatic rise of what former U.S. Surgeon General Richard Carmona defined as an epidemic. The 46-year-old Murrell grew right along with the nationwide obesity trend. "As the years went on the weight did, too," she says. "By the fourth grade, I was 173 pounds. By the time I was in high school, I weighed over 300 pounds." Along the way, she felt the heartache and paid the extra costs associated with obesity.

Murrell's weight peaked at 430 pounds. Her insecurity and what she perceived as discrimination took their toll psychologically. Hypertension, diabetes, congestive heart failure, and degenerative joint disease made her miserable and threatened her life.

A self-inflicted epidemic

Obesity statistics support the epidemic label, both on the national level and here at home. Under 10 percent of the adult population of Tennessee was obese in 1985, according to research published in the Journal of the American Medical Association. The heaviest states then, including Wisconsin, Indiana, Georgia, and South Carolina, had adult obesity rates of 10-14 percent.

By 1991, Tennessee expanded into that bracket, while Louisiana and Mississippi reported that 15-19 percent of their adults were obese.

Talk about a growing trend. Tennessee ballooned into the 15-19 percent bracket by 1995 and had plenty of company. The entire Midwest, every Southern state except Georgia, and the eastern seaboard up to New York had grown at a comparable rate.

According to the Centers for Disease Control, the obesity rates of adult populations in 18 states exceeded 20 percent by 1999. The most recent obesity study, of 2005 statistics, shows the three lightest states with adult obesity rates of 15-19 percent. Remember, 20 years earlier those numbers would have qualified those three states as the heaviest by far. The heaviest states today, and they deserve special recognition — West Virginia, Mississippi, and Louisiana — have adult obesity rates in excess of 30 percent.

Tennessee is catching up fast at 25-29 percent. We may have to loosen the Bible belt. Nine of the top 10 fattest states in the country are Southern.

Doctors here are quick to point to Southern culture as a root cause. "We're famous for barbecue and fried foods," says Steven Gubin, a North Carolina-born cardiologist on the staff of Stern Cardiovascular Clinic in Germantown. "On Sunday after church we have a big supper. I think that's one of the big factors," Gubin says.

Calories per dollar

While no sensible person would argue that our regional cuisine qualifies as health food, it's hard to pin all of the blame on it. After all, pulled pork, fried chicken, and church suppers haven't just come along in the last 20 years. Neither did the tradition of boiling the nutrients out of vegetables and seasoning them with ample cuts of salted pork fat.

Obesity researcher Adam Drewnowski tied the problem to another Southern classic, poverty. His research indicates that poverty is the greatest predictor of obesity in the country today. The correlation of poverty with obesity is a recent development. Look at Walker Evans' photographs of Southern poor during the 1930s in Let Us Now Praise Famous Men, and you'll see poor people as they must have looked for centuries before: gaunt and boney.

The increasing availability of processed foods in the past three decades has fueled the obesity crisis. Drewnowski found that for those on a budget, the bang-to-buck ratio tips heavily in favor of Cheetos and Mountain Dew. He found that a dollar purchased 1,200 calories of chips or cookies, compared to 250 calories of carrots. To wash it down, a dollar bought 875 calories of soda, or 170 calories of orange juice.

Stacey Smith, like Gubin a cardiologist at the Stern Clinic, says that lifestyle changes account for part of the problem down South. "Poor people who don't grow their own food don't have access to healthy food," she says. "It is much cheaper to buy packaged, processed food than it is to buy fresh fruits and vegetables. Healthy food can be more expensive."

The Mid-South has become a prime location for facilities like the Stern Clinic. "Cardiologists in Memphis are quite busy," says Smith. "Unfortunately, it's a good place to practice because many of the high-risk factors for coronary disease are here. The progressive epidemic of obesity leads to diabetes, which is a very high risk factor for coronary disease. Obesity causes high blood pressure, which is another risk for coronary disease, and it's associated with high cholesterol and high triglycerides, which are risks for coronary disease."

Smith says that the role of the cardiologist extends beyond physical treatment and should influence the behavioral changes needed to combat obesity. "It's easy for mothers — when they're working and trying to raise a family and they're tired — to go to McDonald's instead of cooking for their family," she says. "It's easier, it's affordable, but it's not optimal. We have to figure out how to change those choices."

As Gubin explains, obesity is more than a problem in and of itself. It sits at the center of a web of public health issues. "The number-one cause of death in the United States for both men and women is heart disease. Obesity is considered a preventable risk factor of heart disease," he says.

"My friends didn't want to be friends in public."

Back to our walk in Murrell's shoes: Many of us have heard the stunning statistics before, and have some idea of the medical outlook of the situation. But to know what it feels like to be stared at, mocked, and discriminated against — to know what it feels like to live fat — brings a public health issue to life.

"Everybody in our family is huge," explains Murrell. "A lot of it is hereditary, but I'm not going to put it on that by itself. I'm not going to say it was my genes, because it was my appetite — I had a huge one," she says.

School was no picnic for Murrell. Her self-consciousness blossomed after the rude awakening to both her own obesity and the cruelty of children on that first day of kindergarten. "I was 13, or 14, going through school at 300-plus pounds," she recalls. "I had to squeeze into those little desks, sitting there looking like somebody blew me up two sizes bigger than the chair. It was bad. It reached a point where I felt that life was not worth living."

Murrell felt alienated from her classmates. "I was teased and taunted as a child, and as a teenager I felt like I had to do other things to be accepted. That's how I ended up with a baby at 15, because all I wanted was friendship," she says. "All of my friends had little boyfriends. That didn't make me feel any better about myself."

She returned to school after the birth of her child and eventually graduated, though her struggle with depression had just begun. "I landed in intensive care twice with overdoses [the first at age 16]. My wrists are scarred and my arms are cut up. The first three years of my child's life, I was in and out of psychiatric hospitals. It was because of the weight, and the way people made me feel. My friends didn't want to be friends in public."

"You don't dare go into a buffet . . ."

Her depression compounded her weight problems. She self-medicated with food, perpetuating this vicious cycle. Despite her difficulties, Murrell tried to lead a normal life. She entered nursing school. She also tipped the scales at 400 pounds for the first time.

"The more I pushed myself, the harder I tried to be somebody, the weight was always there," she says.

Murrell's world was an unforgiving place. Things that normal people take for granted become humiliating, fearsome chores for the obese. Something as pleasurable as clothes shopping can trigger depression. "They didn't have clothes designed for young people in a fat shop," Murrell says. "I dressed like an old lady all of the time to get something that fit. If I wanted to dress in something that looked younger, it was too tight. I had this hanging out, and had to poke this in, so when I went out I was making a spectacle of myself. I just preferred staying home. Then the loneliness is what really drives you crazy.

"You don't dare go into a buffet because people look at you like, 'What's she doing in here? She's already done enough.'"

New social science research shows that overweight people in the workforce are paid less, promoted less, and fired more. Murrell can attest to these and other stresses on the job. "You are treated differently. I've gone for jobs where I knew I was more qualified than the person that got the job," she says. "But size is a factor in everything."

Murrell's self-consciousness spiraled at work. "I did most of my work in doctors' offices. They only make uniforms to a certain size. I usually had to go to a men's big and tall shop to get the shirt. Sometimes I'd have to get pants there as well. If you're counseling patients, and meeting with patients one on one, they don't want some huge person hovering over their patient. I feel like I lost a lot of jobs because I was huge."

"I was like a zombie for the next 10 years."

The decades of despair took their toll on Murrell. Her big problem, obesity, carried a series of side effects that seemed to feed off of each other while eating away at her spirit and body. "Day after day you get the same thing drummed in your head," she says. "You're fat, you're worthless, you're lazy."

Her family life suffered, though she had two more kids. "I couldn't get close to my family, because I was so consumed with the weight issue. I was like a stranger in my own house. They didn't know me, and I really didn't know them. The weight was all I could think about," she recalls.

Her self-image kept her in dire personal relationships. "You don't feel worthy yourself; therefore, no one else is going to feel you're worthy. I was in horrific relationships, where I was treated awfully, and I stayed in them because I felt like it was all I could get. I was humiliated the whole time. I was more like a bed warmer. I was used and abused," she says.

Murrell tiptoed between life and death, sanity and insanity. Her weight and the web of problems that spun out from it encased her. She felt lost. The cycle seemed impossible to break. Everything she did to make herself happy fed her consuming illness.

"I was eventually put on such high doses of antidepressants that I was just out of it. I had to go on disability from work," she says. "Prozac is usually a one-pill-a-day thing, and pills are 20 mg each. I was on 100 mg of Prozac a day, then they had me on Wellbutrin because I couldn't take any more Prozac. I was taking five times the normal daily amount. Then I had to take something to help me sleep at night because I was on so much stuff to keep me from being depressed. I was on so many meds that I couldn't function. I was like a zombie for the next 10 years. I was in psychiatric care for 20 straight years running. I had no quality of life."

Rock bottom

By then Murrell was fed up. She had tried diets and lost weight, but she always put it back on. Diets tend to emphasize weight loss over lifestyle changes, a recipe for temporary success, but inevitable setbacks. Like other heroes of addict-makes-good tales, Murrell had to hit rock bottom before she committed to helping herself.

"I was in a doctor's office. Most doctors are pushy, telling you, 'You need to lose the weight.' They'd tell me what I need to do, but nobody'd sit down and talk to me, and tell me how to do it. One doctor said, 'Rosie, I've done all I can do, it's up to you.' He said, 'What's going to happen to your kids? You're literally killing yourself.'"

Too unhealthy for gastric bypass surgery

Though the culture of dieting demands drastic changes in the food one eats in exchange for dramatic body changes, the medical community shuns the feast-or-famine approach. "Most obese people want to lose weight, but they want a fast fix," explains Gubin. "If you lose 5 percent of where you start, it's a significant improvement in lowering the risk for hypertension and diabetes. I try to tell people it's not something that needs to be done in a month. I see patients who try fad diets, lose weight rapidly, and gain it back plus more. They have to learn healthy lifestyles."

Murrell thought that she had gone beyond where lifestyle changes could help her lose weight. She feared that surgery was her last chance. "I had been 400 pounds for about 20 years," she says. "I didn't go under 400 until I tried to get in shape for bariatric surgery, and got down to 370 in 2003."

Murrell's doctor tried to refer her for gastric bypass surgery, but as she explains, "My health was so bad that they wouldn't attempt it. They said there was a better chance that I'd die on the operating table than survive the surgery. I lost the 60 pounds but they still couldn't do the surgery because of my blood pressure and diabetes. The answer to the surgery was 'no.'"

"When you get that mind and spirit going, the body is going to follow."

Finally, her doctor told her that her only option was to change everything. Murrell says that she lacked the self-respect to want to help herself. She felt responsible to her doctor, though, and began a lifestyle change program through the Church Health Center (CHC) in 2005. She weighed 370 then.

The first steps humbled Murrell. "When you're on the treadmill, and you're a size 46, and you're running — well, you're walking, 'cause you can't run — next to a size six, that's funny for the people behind you. You're a joke then for trying to exercise. It's torture."

A CHC nutritionist told her to increase her caloric intake. Increase? Murrell cried. But soon she understood that weight loss required energy. "I had wanted to risk death with the surgery, so why not risk a couple more pounds? I tried the increase, and at first I gained a couple of pounds. Then I started to exercise. I lost a couple of pounds. Then they started to come off four and five pounds a week. They kept coming, and I started grinning," she recalls.

The CHC Healthy Bodies program taught her portion control and healthy recipes. Murrell and other members attend health classes and support group meetings. She exercised. She also began the process of exorcising the demons from her past. "Everywhere else, they focus on the weight. They didn't realize that underneath it was another problem: the turmoil that I had put myself through. Here they focus on the mind, body, spirit, and soul," she says. "When you get that mind and spirit going, the body is going to follow."

The holistic approach was just what she needed. "I was 370 when I got here. Now I'm 170 pounds lighter," she says. "Now I feel like I'm 16 because I just didn't have a life in my younger years."

As physicians promised, Murrell's weight reduction resulted in a reduction in her medication. "It's gone from 20 pills to four," she says. Murrell has reversed her diabetes and gotten off painkillers.

Despite her triumph, though, the irreversible physical damage done during her decades of obesity persists. She still suffers from congestive heart failure and degenerative joint disease. And the psychological scars haven't fallen away with the pounds. "I'm still in counseling. I don't feel like I'm ready to give that up yet," she explains. "I can get over being fat, because I can lose the pounds, but I can't forget about what happened to me during those years. I lived through it for so long, and I'm working through it now. We're working through the things I did to be accepted. Peer pressure itself makes you do things you're not proud of, but I had the extra pressure of being overweight and trying to fit in."

"That's all I want to be — average."

Physicians say that patients hoping to lose weight should be prepared for a long process. It took years to put the weight on, they reason, so the fat won't vanish overnight. The same is true for breaking cultural and familial patterns of obesity. It takes generations to ingrain healthy lifestyles in families. "The types of foods that people eat are hard to change at the level of culture," says Smith. "That's something that changes over time as people learn to cook more healthily, they get their children to like this kind of food, who subsequently feed their children healthy food. It's a generational thing that changes slowly over time. It's a real task to change the foods people eat, and portion control."

Though the Surgeon General called it an epidemic, it's still treated as an individual problem.

"Changing this should be a social priority," Smith says. "We've been taught to eat far beyond what our physical needs really are. That's hard to change. If you learn how to do it slowly over time, you're much more likely to live a healthy lifestyle."

"The goal is to get each state below 15 percent obesity of the adult population. That's lofty," says Gubin of a figure that just 30 years ago would have required an initiative to fatten people up. But we're a bigger country now. What was unhealthy 30 years ago is average today. The epidemic feeds on lower standards.

"I'm in a size 20 now," Murrell says. "I don't want to get smaller than a size 14 or 16. I've never wanted to be thin, all I wanted to be was accepted. To me a size 14-16 in America now is average. So, that's all I want to be. Average." 



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