Research has shown that a woman’s body shape—whether she is round in the middle like an apple or wider at the bottom like a pear—is the single best predictor of health risks. Dr. Marie Savard wants to get this message out to all women, so that “pears” can give themselves a break from pointless dieting and “apples” can save their own lives.
By Caroline Tiger
Sidebar | Supersizing for Good?
When Dr. Marie Savard Nu’72 GrNu’72 M’76, walks into the lunchroom at the Center City Philadelphia offices of Binswanger, a real estate consulting and brokerage firm, to talk about her book, Apples and Pears: The Body Shape Solution for Weight Loss and Wellness, everyone’s already seated. Though talking about your weight and health is a bit personal for office-lunchroom fodder, the promise of a new and effective weight-management plan is irresistible—25 women of varying ages and shapes are assembled.
Savard, 55, is adept at putting the standing-room-only crowd at ease. Like all good public speakers, the slim, blonde doctor opens with a joke—“Mr. Binswanger told me I get a better turnout than he does”—but she immediately undercuts the effect by pulling a tape measure out of her purse. The women sitting up front suddenly look horrified that they might be rounded up and measured.
Savard launches into her talk by asking a few questions. “How many of you in here know how much you weigh?”
Everyone groans. Everyone raises their hand.
“How many of you know your waist and hip size?”
Some women grumble. A few put their hands up, weakly.
“How many of you had your doctor measure your waist during your last doctor’s visit?”
At this prospect, the women out and out giggle.
“As it turns out,” Savard continues, slowing down to be sure that the women are paying attention to what she’s about to say, “In all seriousness, the tape measure is the most powerful tool that your doctor has to predict your future health risks, even more powerful than your blood pressure, your cholesterol, even more important than all those fancy new tests you hear about, than your family history.” She pauses. “What does this mean? Why aren’t more people talking about this?”
In Apples and Pears, Savard doesn’t claim to break new ground. Before it was published, researchers knew that belly fat was linked with heart disease. The book’s reference section lists 33 pages of related studies. But Savard is the first person to compile all of the data and put them together in a way that makes sense to every woman, whether she’s a corporate executive in Manhattan or a stay-at-home mom in Duluth. Ever since 1997, when Savard began to shift her career from running a private practice to educating and writing, her work has been all about teaching people to become active agents in their own healthcare. Her 2000 book, How To Save Your Own Life: The Savard System for Managing and Controlling Your Healthcare, focused on patient empowerment [“Alumni Profiles,” July/August 2002]. And Apples and Pears does, too—but, more specifically, it arms women with a new way to think about weight and the important role it plays in their health.
Since the book came out early this year, Savard has been on the road spreading its gospel. At her appearances at bookstores and in front of health organizations, she always gives a measuring demonstration, wrapping the tape measure around her own hips. It’s all part of her mission to shift the gist of the discussion from weight to body shape, from shame to acceptance, from aesthetic ideals to health ideals. She wants to get women talking about their bodies as shapes that they’ve inherited instead of as disloyal blobs that refuse to fit into skinny jeans.
At the root of this mission is Savard’s regret that her sister, Millie, didn’t have this research at her fingertips before she was diagnosed 12 years ago with neuropathy and adult diabetes. Whenever she sees an overweight apple-shaped woman, she sees a potential Millie. She sees some today when she looks out at the women gathered in the lunchroom. “It’s too late for my sister,” she tells them. “Once you have this disease, you can’t get rid of it. But you can prevent it.”
When Savard was a girl growing up in York, Pennsylvania, she and three of her four sisters were always borrowing each other’s clothes. Because they sewed, they noticed that they needed bigger patterns on the bottom and smaller patterns on the top to fit their flat chests, small waists, and big hips. Millie was the only sister who couldn’t partake of the clothes-swapping. Millie took after her dad’s side of the family—her body was more straight up-and-down, what Savard now calls an “underweight apple.”
Savard filed this information away in the back of her head as she went through nursing school and medical school. In 1976, the same year she received her medical degree, her mother was one of 120,000 nurses who agreed to take part in the Nurses’ Health Study, a National Institute of Health-funded study run by Harvard researchers to investigate the risk factors for major chronic diseases in women. Every few years, they sent Marie’s mother a questionnaire. Throughout the 1970s, they’d ask for her height and weight. Sometime in the 1980s, they began asking for her waist and hip measurements. It became a Savard family joke that her mother went to measure her waist and all her father, a mechanical engineer, had to offer was a slide rule.
Meanwhile, Savard began practicing as a general internist and noticing body-shape-specific patterns in her patients. She noticed that her menopausal, bottom-heavy patients had no side effects from estrogen therapy. She’d prescribe hormones for them, and they’d soak it up. But other women would blow up from the hormones. Their breasts would get bigger and their blood tests might come back a little peculiar. Their bad cholesterol would be really low, their triglycerides would be kind of high, and their blood sugar would be borderline. Sometimes their liver tests would be slightly off. The gastrointestinal doctor would notice that there was a little fat in their liver. All of this would happen to the women who were “top-heavy,” as Dr. Savard called it back then, like her sister, Millie.
In 1998, Savard was appointed medical director of the Center for Women’s Health at the old Medical College of Pennsylvania, and she signed the contract to write How To Save Your Own Life. She went on the lecture circuit to talk about women’s health issues. At her talks she used a slide of an apple sitting next to a pear to illustrate belly fat, one of the factors that contributes to heart disease. In the 1990s, researchers were finding that fat was a metabolically active tissue rather than a space-filler, an inert mass. They found that the subcutaneous fat that collects around the thighs, hips, and buttocks, is harmless—at least until it becomes heavy enough to put a strain on the heart and joints. But the visceral fat that wraps itself around our organs and muscles is a much more active organ, releasing fatty acids into the bloodstream, causing inflammation and raising blood pressure. Though studies citing the importance of waist circumference as an indicator of later health problems were out there, the average American who wasn’t up on the Annals of Internal Medicine wouldn’t have noticed.
Savard didn’t connect the dots, either, until the results of the Nurses’ Health Study were published in a book called Healthy Women, Healthy Lives. Savard’s mother sent it to her as a gift in 2002, and when she sat down to read it, all of the seemingly random pieces of information that had been swimming around in her head came together. “It crystallized,” she recalls between sips of coffee, sitting in a conference room after the lunchroom talk. While she was reading the book, she kept a supply of yellow stickies nearby, and she marked page after page, underlining passages that resounded. It was a rush. “I had had this sixth sense that we were missing something,” she says, “that there was something that didn’t add up. And it was like the more I looked in the book, the more I found.”
She kept jumping up and interrupting her reading to check each chapter’s references online. She found that people had been studying body-fat distribution for some time, especially in Europe and in the U.K., where there are more apple-shaped women. “Oh my god,” she thought, “the whole world of women’s health should be viewed through the lens of body shape.” This was why women looked so complicated to researchers, why the studies never showed what the doctors wanted them to show.
The perfect example happened to be in the news—the NIH had just halted a study on the effect of estrogen on post-menopausal women because of a demonstrated increase in risk of stroke and little evidence that the hormone prevented heart attacks. But the Nurses’ Study found that estrogen reduced the risk of heart disease by 50 percent. How could the studies oppose each other so completely?
Savard realized that the halted study had only looked at apple-shaped women. The researchers discouraged women with hot flashes from applying, since they didn’t want their subjects to be able to tell whether they were receiving the placebo or the hormone. Limiting their subjects this way effectively cut out pear-shaped women, since they don’t have the visceral fat that continues to produce estrogen post-menopause that cuts down on hot flashes.
“I was like, ‘Oh my god, we’re making assumptions about all women based on 65-year-old apple-shaped women who are already naturally full of hormones,” says Savard. “Of course they did worse.” In chapter after chapter she read that women shaped like apples are more likely than pears to get breast cancer, to get heart disease, to get osteoporosis, and to get diabetes as well as its precursor, metabolic syndrome.
All of this could have meant a world of difference for Millie. If someone had linked her borderline cholesterol and blood sugar with her high-risk body shape, she might have been able to guess—and prevent—what would be in store if she didn’t lose those inches around her waist. Savard saw now that she could have advised her sister to make certain lifestyle changes that may have kept her from getting diabetes. She could have taken the easiest preventive measures, such as swallowing an aspirin a day or taking a folic-acid supplement. Preventing an incurable disease might have been an effective incentive for her to lose her excess weight.
Back at Binswanger, Savard is advising her charges on recommended plans of action for their body shapes. “If you’re a pear-shaped woman who’s overweight,” she says, “your doctor shouldn’t give you a hard time and tell you to lose weight. If you’re healthy, if you’ve got a small waist size, don’t worry about it; it’s good for your bones to be a little heavy.” The pear-shaped women in the group can hardly believe that someone is telling them it’s OK to be overweight.
In her book, Savard explains that the biggest harm done by pear-zone fat is the damage it causes to a woman’s self-esteem. This subcutaneous fat is nearly impossible to shed, unyielding in the face of any combination of squats, lunges, and fad diets.
“However,” she continues, “a woman who’s slightly overweight with a big waist, the doctor shouldn’t say, ‘Oh, it’s a touch of sugar, no problem.’ He shouldn’t say, ‘Oh, the cholesterol, it’s borderline, no problem. Instead he should be saying, ‘Wow, you have an opportunity to do some things we know will change your chances of getting all of these different diseases.”
After the talk wraps up, most of the women thank her and leave to return to their work. A few hang around to nibble on the fruit provided in honor of Savard’s appearance. Doree, a “luscious pear” in apple-and-pear parlance, nibbles on a slice of cantaloupe. “I went to my doctor and told her I’d lost eighteen pounds,” she says. “And she said, ‘You still have a long way to go.’” The women standing around the office kitchen shake their heads. These are the kind of stories that drive Savard crazy. “For what?” she’ll ask herself later, thinking back on Doree. “At what cost? What is the goal? Does she feel good about herself? Is she healthy? Are her blood parameters all good?”
Her message continues to be bolstered by new findings. In the months since the book came out, researchers have continued to reinforce the message that butt-fat is harmless and gut-fat is not. In May, the University of Colorado published a study linking abdominal fat with damage to the arteries. In April, the University of Pittsburgh reported the results of a five-year study of 90,000 obese women—they found that apple-shaped women had higher health risks than pear-shaped women, even if they weighed the same. “People think of obesity as a single thing, but your risk can be modified within that,” lead researcher Dr. Kathleen McTigue told the American Heart Association when she presented the results. February’s issue of the American Journal of Clinical Nutrition published the results of a study of 10,000 people that concluded waist size was a better predictor than body fat of heart disease.
Savard is excited about her colleagues’ findings. She can’t deny that her timing is good—Apples and Pears seems to have come out just as the gut-versus-butt message is reaching a tipping point. What’s most exciting for Savard is when she sees evidence that she’s chipping away at the predominant mindset in women that prioritizes weight issues over good health. She saw this in Doree’s frustration with her doctor and in Jenn, a young, ample woman in an orange T-shirt and snug black pants, who is scooping sliced fruit onto her plate. “My doctor always tells me, ‘You’re really healthy for a heavy person,’” she says, reaching a hand around to give her butt a resounding slap. “I say, ‘Hey Mama, thank you very much!’”
Imagine that—a woman thanking her mother for passing along her big-butt genes. Dr. Savard smiles. It’s a start, but the scope of her mission is far wider than educating a single roomful of women. Later that day, she hints at that scope by suggesting what her tombstone might read: “She truly was one of the pioneers in putting patients at the center of their healthcare,” she starts, “and she was one of the pioneers who gave women the vision to look at health rather than weight as their measure of who they are and their self-esteem and value.” An appropriate addendum to this already prolific epigraph might be the Ursula LeGuin quote that Savard recites at the end of every talk: “As a woman’s real power grows and her knowledge widens, ever the way that she follows grows narrower until at last, she chooses nothing but does only and wholly what she is meant to do.” She sums it up in her own words: “All of you have the knowledge. You have the power to choose what you are meant to do.”
Caroline Tiger C’96 is a freelance writer in Philadelphia and the author, most recently, of The Long-Distance Relationship Guide.
Supersizing for Good?
The notion of watching what you eat takes on a whole new meaning when you’re Dr. Barbara Rolls CW’66, author of Volumetrics Weight-Control Plan and more recently, The Volumetrics Eating Plan. As the Guthrie Chair of Nutritional Sciences at Pennsylvania State University, Rolls, 60, oversees a revolving staff of more than 20 undergrads, grad students, and researchers, who spend their days at the university’s Laboratory for the Study of Ingestive Behavior literally watching and weighing what people eat—and what they leave behind on their plates.
Test subjects dish out their own portions from hot buffet stations and bring their bounty back to one of the cubicles set up for optimal chewing-viewing. Behind the booths’ blue curtains, small cameras broadcast images to screens in the kitchen and in the researchers’ offices. These images feed Dr. Rolls’ and her colleagues’ growing repertoire of studies that catalog the way humans eat.
Rolls has been researching eating and drinking behavior for 30 years—her interest in the field dates back to her days as a premed biology major at Penn. After graduation she deferred enrollment to medical school to study at the University of Cambridge on a Thouron scholarship, and stayed in the U.K. to earn a Ph.D. in experimental psychology before returning to the U.S. in 1984. She began studying satiety in the 1980s, when she was among the first to make the observation that humans will eat more if they’re presented with a variety of foods. After a stint at Johns Hopkins as an associate professor of psychology, she moved to Penn State in 1991.
At first Rolls and her colleagues went along with the tide of the dieting-industrial complex, which was focused on low-fat, high-carb, and high-protein diets. But Rolls noticed something else going on—that people seemed to eat for volume or for weight of food rather than for calories. Give them unlimited access to food, and they’ll eat the same volume over a day or two. “Once you start seeing that happening,” she says, “it means you need to figure out ways to help people eat a satisfying volume of food while they’re consuming fewer calories.”
She nosed around in the annals of food-behavior studies and found an article written by researchers at the University of Alabama in 1983. Their subjects felt full on half the calories when they were eating low-energy-density foods, or foods that are packed with water. In light of her findings on volume, the study made sense. What increases volume without increasing calories? Water. “We were so focused on proportions of fats, carbs, and proteins in foods,” Rolls recalls, “that we had overlooked water content and yet, as it turns out, water has the biggest impact on the amount of food.” She started to take a closer look at the effects of water-packed foods on satiety.
One of her first studies involved “preloading” test subjects with milkshakes that came in different volumes, but that contained the same number of calories. Some subjects were given 600-milliliter milkshakes to drink 15 to 20 minutes before sitting down to eat a meal. Others were given 300-milliliter milkshakes that had half the water content but the same number of calories. Those who drank the water-drenched milkshakes ended up consuming 100 fewer calories. Volumetrics was born. Well, the theory was born. Its name came much later, after Rolls played with hundreds of tentative titles. “When you’re doing a diet book,” she points out, “you need something a little different because there are so darn many books out there.”
Her Volumetrics Eating Plan, the sequel to her 2000 book, was published last March. It’s a practical guide to eating the Volumetrics way—lots of water-rich fruits and vegetables, broth-based soups, whole grains, and legumes.
Rolls and her colleagues recently conducted the first yearlong clinical trial to assess the effectiveness of the program. Half of a group of 97 obese women followed a Volumetrics plan and the other half was given more traditional dieting strategies that restricted fat and portion sizes. The first group ate a greater volume of food, but lost more weight—an average of 20 pounds. They also ate a more nutrient-rich diet, full of fruits and vegetables. The second group lost an average of 15 pounds. Of course, as Rolls says, “The tricky part is keeping it off.”
In 2004, Rolls was the first scientist called in to testify before the federal government’s Dietary Guidelines Advisory Committee; the 2005 guidelines reflect her findings in their recommendations to restrict portions of high-energy dense foods. In May she traveled to Italy to attend a meeting on the Mediterranean diet, and the health professionals there were talking about energy-density as a way of managing body weight. She’s even spotted the term volumetrics, with a lowercase v in several scientific journals. “It’s pretty exciting,” Rolls admits.
Still, there’s a long way to go. The rest of the world has energy density—listed as number of grams per 100 calories—on their nutrition fact labels, and Rolls hopes that America will adopt this practice. This information would allow a consumer to pick up two bags of potato chips and determine immediately which one will give you the most amount of food for the least amount of calories—kind of like supersizing for good, not for evil.