Two-thirds of Americans are overweight or obese, yet they live in a culture that glorifies thinness. From actors to models, athletes to adolescents, millions of Americans are preoccupied with making their bodies slim and fit.
Enter the fad diets, the quick weight-loss fasts, and the multibillion-dollar diet-supplement industry. Some promise body perfection, a diet miracle in a pill that can slim you down in a matter of weeks.
But since the death on Monday of Baltimore Orioles pitcher Steve Bechler, who had reportedly taken the weight loss supplement Xenadrine RFA-1, the quick-weight loss industry is coming under new scrutiny.
Experts say many diet pills are much more dangerous than consumers realize. As a result, advocacy groups are calling for stricter regulation of the industry - and reviving the enduring debate over a nation that obsesses so much over image and inseams.
"We're a fat society that doesn't want to work hard to lose weight, so we turn toward easy solutions and one of those is taking a pill," says Michael Shlipak of the San Francisco Veterans Affairs Medical Center.
Ephedra, the all-natural stimulant contained in Xenadrine and dozens of other supplements is, generating the most controversy. The FDA is investigating whether it played a role in Mr. Bechler's death, and suggestions that it be banned are coming from Congress and the sports pages. It's already barred in the NFL and collegiate and Olympic sport.
But health experts caution that the whole diet supplement industry can be risky because oversight is so spotty: Unless a supplement is proven to be unsafe, it isn't regulated by the Food and Drug Administration (FDA.) As a result, the quality as well as the dosage can differ dramatically from one product to the next, leaving consumers to play a kind of Russian roulette with their health.
"We've moved to a pre-FDA era with these products," says Dr. Brian Strom of the University of Pennsylvania. "People are fooled into thinking because it's natural, it's safe, when in fact, because it's natural, it's unsafe in this case. It's chopped-up plants."
Defenders of the diet supplement industry, and ephedra in particular, contend the products have been proven to be safe when used as directed. Shane Freedman, the general counsel for Cytodine, the New Jersey company that manufactures Xenadrine RFA-1, says that seven clinical studies have verified ephedra's safety and effectiveness.
He also notes that a toxicology report on what was in Belcher's system at the time of his death will not be available for another two weeks. "It's unfair to draw any conclusions now," says Mr. Freedman. "The science shows that it's safe when used as directed."
Still, critics note that ephedra has a history of producing health problems. A study that will be published in the Annals of Internal Medicine in March finds that 64 percent of all the adverse reactions reported to poison-control centers around the country that deal with herbal supplements had to do with ephedra.
"Ephedra is clearly unsafe when compared to other herbal supplements," says Dr. Shlipak. "It's 200 times more risky than the average herb."
Because of such controversy surrounding ephedra in the past, the FDA has commissioned the Rand Corporation to do a study on the supplement. That report is due out next month.
Despite the controversy over ephedra's safety, an estimated 12 million Americans use diet supplements that contain the herbal supplement, helping to make it a $3 billion industry. That doesn't surprise Dr. Shlipak. He says as Americans have become increasing less active, they've also become more obsessed with health.
But some weight-loss experts believe such supplements are vital to helping many overweight Americans cope. Carlon Colker, a weight-loss doctor in Greenwhich, Conn., says the message that Americans should simply eat healthily and exercise "just isn't working." If it were, he argues that obesity-related problems from heart disease to diabetes would not be increasing as quickly as they are right now. He contends supplements like ephedra, which he says is "absolutely safe" when taken as directed, give many Americans the extra push they need to begin taking proper care of themselves.
"I use countless pharmaceutical and non pharmaceutical substances to give people a little jump start - just telling them to eat right and exercise doesn't always work," says Dr. Colker. "Why should we take the most powerful, cost-effective tool that we have out of the hands of the public?"
While no one would dispute that America is coping with a serious weight problem, eating disorders are also a major problem - in part, a result of the commercial preoccupation with thinness. For both men and women, it's equated with success and sexuality. Many women, in particular, tie their sense of self-worth to their body.
"Thin is really part of what it means to be attractive within this culture," says Sharlene Hesse-Biber, a sociologist at Boston College. "The message is that you have to shape up to the right kind of body. We punish and reward people for having the right or wrong body."
And that, she believes, has created a "cult of thinness" that leads some people to diet extremes that can be harmful. It would be better, she says, to forget what we look like and focus on what we do and being healthy.
"We have so much hatred directed toward our bodies that marketers play to - fat is the f-word," she says.