Debunking some of the most widely repeated myths about fat and health.
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Michael: What have you got? What's your tagline? What's your intro?
Aubrey: Oh, man. I'm realizing right now that I have given zero thought to it.
Michael: Do you even know what this episode is about? [laughs]
Aubrey: It's about statistics, yeah?
Aubrey: The phrase that you keep using is zombie statistics.
Aubrey: Hi, everybody and welcome to Maintenance Phase, the podcast that brains.
Aubrey: What do you think?
Michael: That was good. You went the direct route. I like that.
Aubrey: I went very direct. There were other options. They were two.
Michael: I am Michael Hobbes.
Aubrey: I'm Aubrey Gordon. If you would like to support the podcast, you can do that at patreon.com/maintenancephase. You can also get t-shirts, masks, tote bags, mugs, all kinds of stuff at TeePublic. Both of those things are linked for you in the show notes.
Michael: And speaking of show notes, I have a new YouTube video. I'm doing a series, where I break down moral panic articles and I just made a video about a New York Times editorial about the free speech crisis, which isn't a thing and we'll leave a link in the description or you can just Google Michael Hobbes YouTube, and it'll come up.
Aubrey: And today, Michael, we're talking about brains.
Michael: [laughs] Okay. This is a penance episode.
Michael: If you follow us on Patreon, you know that we didn't get our bonus episode out last month and we had to delay last week's episode. The reason for all of this is that, while I was reading Michael Pollan's book, in the first chapter, he has a five-paragraph section, where he talks about like the ravages of obesity. It's just zombie statistic after zombie statistic. It is the kind of thing that you and I have read 5 million times. I read this and I was like, "Don't look it up, Mike. Don't do it. You have to research this one episode. You don't have time." And then I was like, "I'm just going to look up one." He looks five statistics. I'm like, "I'm just going to look into the first one" and then a day went by.
Michael: And then, I just went down like a huge debunkie rabbit hole on this extremely small section [laughs] of Michael Pollan's book. Eventually, I pulled my head up and I was like, "Oh, I have an actual show to make." Then we ended up doing all this other stuff, but then I wanted to do a specific episode about this couple paragraphs in his book. Not to do any further roasting of Michael Pollan, but because these statistics show up everywhere.
Aubrey: These are the episodes that when you tell me about them, I'm like, "Ah, is it not going to be the most dry thing ever?" And then, behind these statistics are truly the wildest goddamn stories.
Michael: You're telling me is that, you're ready to be bored.
Michael: But also, ready to be pleasantly surprised.
Aubrey: Awesome. Let's do it.
Michael: So, I'm about to send you the roughly three inches of text that we're going to spend roughly three hours talking about.
Michael: Okay. Here they are.
Aubrey: "The alcoholic republic has long since given way to the Republic of Fat. According to the Surgeon General, obesity today is officially an epidemic. It is arguably the most pressing public health problem we face, costing the healthcare system an estimated $90 billion a year. Three of every five Americans are overweight, one in every five is obese. The disease formerly known as adult-onset diabetes has had to be renamed to type 2 diabetes since it now occurs so frequently in children. A recent study in the Journal of the American Medical Association predicts that a child born in 2000 has a one in three chance of developing diabetes. An African-American child's chances are two in five. Because of diabetes and all the other health problems that accompany obesity, today's children may turn out to be the first generation of Americans, whose life expectancy will actually be shorter than that of their parents."
Michael: Initial thoughts.
Aubrey: I hate it.
Michael: [laughs] Twist.
Aubrey: Everything about this is, it's just the greatest hits of anti-fat people trying to insist that anti-fatness is right and natural and for the greater good.
Aubrey: It is a really fucking gnarly way to talk about fat people.
Michael: So, indeed gnarly department, maybe it will not shock you-
Michael: -but I have read all of these a million times and none of them check out.
Aubrey: I am most curious about this cost to the healthcare system number. I feel there are different numbers that get thrown around and they are always in the billions.
Michael: Oh, yeah.
Aubrey: I have no earthly clue, where those numbers come from. I have no earthly clue, why they're different every time.
Michael: So, can you read this sentence one more time just to remind everybody what we're talking about?
Aubrey: Okay. "According to the Surgeon General, obesity today is officially an epidemic. It is arguably the most pressing public health problem we face, costing the healthcare system an estimated $90 billion a year.
Michael: My beef with these numbers-
Aubrey: Tell me.
Michael: -they appear on the surface as if they fulfill an informational function. It's like, "Oh, a piece of information, right?" I learned how much America spends on obesity every year. But what they're actually doing is serving a rhetorical function. Because that number is utterly meaningless. $90 billion a year. Okay, how much do we spend on healthcare total? How much do we spend on cancer every year? That number could be $45 billion and that number could be $500 billion, and you'd probably have exactly the same reaction. You'd be like, "Wow, that's a lot."
Aubrey: Right. As an individual person, who's in charge of managing my individual finances, $90 billion sounds like an unthinkable amount of money.
Aubrey: I think part of how these statistics are deployed count on that.
Aubrey: Count on. This just sounds like an astronomical amount. There're so many judgment calls that go into this. The assumption here and the way that it's deployed is, fat people are costing you $90 billion. Think about what you personally could do with $90 billion.
Michael: Yeah, exactly.
Aubrey: It's not explicit, but the implicit message is really clear, which is it's fat people's fault.
Michael: Yeah. [unintelligible [00:06:25] They're costing me money, man. Yeah, exactly [unintelligible [00:06:27].
Aubrey: You can turn into the penguin from Batman.
Michael: The primary way that you can tell that nobody cares about these numbers or where they come from is that, Michael Pollan uses the wrong number.
Michael: This appears to come from a 2004 paper called The Escalating Pandemics of Obesity and Sedentary Lifestyle.
Michael: This actual study finds that the costs are $70 billion, but then it cites a 1995 study that found $99 billion dollars. Somehow $99 billion became $70 billion became $90 billion in Michael Pollan's book.
Michael: This again to me is just like, "No one fucking cares. They needed a big number." But what really jumped out to me is from this 1999 article that says, the cost of obesity was $70 billion. It says that it's 7% of total US healthcare spending, which to me sounds like a bargain actually.
Michael: This is from the 1999 article. It says, "In the absence of obesity, Medicare and Medicaid spending would be 9% and 12% lower respectively."
Michael: Which also, A, sounds like a bargain. Secondly, you can find records from the 1960s that show that 12% of the US was "obese" according to current BMI statistics. In the 1960s, 35% of the country was "overweight" as well. So, in the absence of obesity, when the fuck are we talking about it? Like the 1300s?
Aubrey: Well, here's the thing. So, listen. Obesity is a deeply fucking stigmatizing term, right?
Michael: Yes. Obligatory linguistic-- [crosstalk]
Aubrey: General, heads up. We're going to be using this language, because it's going to be all over the research that we're talking about.
Aubrey: It literally in Latin translates to eating oneself fat.
Michael: Oh, really?
Aubrey: Yes. That is the Latin translation is like, "You ate so much, you got so fucking fat."
Michael: Someone's researching her new book-
Michael: -reading the Latin.
Aubrey: It's just worth knowing that that is the stigma is built into that term.
Aubrey: Fat people, who are most of us are being made to listen to all of these public health declarations about like, "If only we could get to a world where fat people didn't exist, where most of you work here." And that is a wildly heartless thing to say.
Michael: But Aubrey, what if I'm making that argument to say that it would be cheaper for a group of people.
Aubrey: God damn it, Michael.
Michael: Not even better qualitatively.
Aubrey: Okay, but what about the cost saving?
Michael: What about the cost savings of this group not existing?
Aubrey: What about the cost saving?
Michael: [laughs] What about using this for the most offensive kind of cost benefit economic analysis imaginable?
Aubrey: Jesus, God.
Michael: What about that, Aubrey?
Michael: But then, okay. This is just conceptually gross and shouldn't exist. But of course, as part of my rabbit hole tumbling, I started looking at the other numbers, because as we noticed with this number itself in Michael Pollan's book, there's no consistency. These numbers bounce all over the place. I started looking at the canonical "costs of obesity," throughout time. The earliest I could find was 1990, a study estimated the cost of obesity at $46 billion.
Michael: There's a 1994 paper that says $70 billion. There's a 1998 paper that says $78 billion. There's this 1999 paper, the Pollan references that says $99 billion. So, from 1990 to 1999, the costs of obesity have somehow doubled. They've gone from $45 billion to $99 billion.
Aubrey: Can I take a swing at one of the factors?
Michael: Oh, do it.
Aubrey: The definition of obesity changed.
Michael: Oh, yeah. I know.
Aubrey: You lowered the floor for who you consider fat and then you're like, "Fat people cost us so much money" and didn't mention we have millions more people who are now medically defined as fat, because we changed the definition.
Michael: We're now at $99 billion in 1999. There's then a 2008 paper that says $147 billion, a 2016 paper that says $261 billion and another 2016 paper that says $481 billion.
Aubrey: What is happening? So, these are wildly disparate numbers.
Michael: This doesn't actually indicate a growing cost or a growing problem. This indicates different methodologies.
Aubrey: I'm curious about-- I'm assuming you got way the fuck into where did all these numbers come from?
Michael: Oh, you know. You know I did.
Aubrey: I know you did.
Michael: You know I looked at them.
Aubrey: Yeah. What did you find?
Michael: I found a 2016 meta-analysis that looked at 23 different estimates of the costs of obesity over time. It's actually a fascinating article, because it has this deep air of confusion, where they look at all of the different methodologies that people use and everyone basically does the same thing. They basically look at various health conditions and they'll say, "Okay, obesity accounts for 40% of this one, and 60% of this one, and 90% of this one," and then they count up the costs. There's this Medicare survey thing of like, "How much America spends on pancreas cancer every year? How much America spends on elbow pain?" It's this whole list of costs and then you just do the math. They're all using essentially the same structure to come up with these estimates. But what this meta-analysis finds from 23 studies, some of them include 30 cancers and some of them include one cancer. This is from the review. It says, "Musculoskeletal disorders were considered in nine studies, respiratory disorders in six, and digestive diseases in five studies. Four studies included mental disorders such as depression."
Michael: We're now in an area where it's like, "Oh, the costs of depression therapy are now obesity related costs?"
Aubrey: Oh, my God.
Michael: There's no way to make the claim that it's caused by obesity. Again, it's just this cluster of correlations. We've talked about this a million times. People with less education are more likely to get various cancers and heart disease. People who have never been married are more likely to have high mortality rates. People who live in Massachusetts live 10 years longer than people, who live in Mississippi, where all of us are these bundles of correlations based on various demographic characteristics and what they're doing is, they're putting obesity basically at the top of that list. Obesity is the most important thing.
There's a think tank report in 2016. This is the one with the highest estimate of the cost of obesity. This is $481 billion a year. I actually appreciate them doing this. They list 23 conditions and the various risk rates for fat people and for nonfat people. One of the ones they list is Alzheimer's, that apparently fat people are slightly more likely to get Alzheimer's. They then say that fat people are responsible for 29% of the healthcare spending on Alzheimer's every year.
Aubrey: I hate this, Mike.
Michael: It's just a fucking gross exercise, but it's also just completely wrong. One of the ones I was going to-- I was going to throw my laptop out the window. One of the ones that's on there, 31 million Americans have chronic back pain and apparently, because fat people are more likely to have back pain. They then say that 18 million of those cases are obesity-caused back pain.
Aubrey: What? They're fully just going, "Well, if thin people have back pain, that's because they have back pain and a fat people have back pain, it's because they're fat, and it's an obesity-related cost and look at those jerks taken all your money."
Michael: Not completely. They do reduce them.
Michael: If obese people have 10 million cases of chronic back pain, they'll say like, "Well, 7 million of them are attributable to obesity."
Michael: It's not 100%, but they are attributing a huge percentage of healthcare conditions to obesity without actually looking into any of the actual complexities of these. The one that I really got stuck on, one of the ones in this analysis is gallbladder cancer, that fat people are more likely to get gallbladder cancer than thin people, fine. There're 8,000 cases of gallbladder cancer every year and they're attributing 4,000 of them to obesity. 4,000 cases of gallbladder cancer are like obesity-related gallbladder cancer. But then you start looking into gallbladder cancer, first of all, as we've discussed before, one of the risks of gallbladder disease, which is a precursor to gallbladder cancer is dieting. Because when you rapidly switch to a low calorie or low-fat diet, your internal systems go haywire and you're producing all this bile, and that puts more stress on your gallbladder system.
Michael: Women are three times more likely than men to get gallbladder cancer, which I'm not going to say dieting is 100% of the reason for that, but women are also more likely to diet than men.
Aubrey: And fat people are under the greatest pressure to lose weight.
Michael: Well, also, one thing that you find throughout these lists in this study and in other studies is that what they call the cost of obesity is actually the cost of discrimination against fat people. One of the interesting things about gallbladder cancer is, it almost exclusively happens in people between 85 and 89 years old.
Michael: Yeah. It's a very rare cancer and it's almost always fatal, because people don't really get tested for it and it's oftentimes diagnosed really late. First of all, we know that at higher ages above 70, fat people actually have lower mortality rates than thin people. We're not entirely sure why, but it's actually protective to be fat in old age. We also know that fat people are less likely to seek medical care and they're less likely to get scans that they need. Oftentimes, they go in with some sort of symptom and their doctor says, "Eh, come back when you've lost 50 pounds." Some, I'm not going to say all, but some of the higher cancer rates for fat people are actually because they're not getting high-quality medical care and they're not getting tumors taken out of them when they need to.
Aubrey: Well, and many of the health conditions that are popularly believed to be the result of fatness are also actually linked to this phenomenon that researchers and sociologists called minority stress, which is the stress of living with racism, and classism, and massive systems of oppression bearing down on you. There's a little bit of research that's on the hypertension stuff that's like, "Oh, it turns out that that might be the result of stigma." They did one study. It was a teeny-tiny study. So, green assault of adolescents, when they experienced stigma on the basis of their size or appearance, and they measured their blood pressure while all of that was happening and fucking surprise, surprise. When people are addicted to you, your blood pressure goes up. There's also stuff like that that we're not accounting for and we're just ascribing all of this to, "Your body has more adipose tissue than a thinner body and you must have done that to yourself. And therefore, you are to blame for whatever befalls you," right?
Michael: Right. Well also, one thing that I got really frustrated by looking into gallbladder disease specifically was how few studies look at anything other than obesity. I found a relatively small study in Iran that looked at 300 women with gallbladder disease and actually asked them a much wider range of questions about their lives. This is from the study. It says, "Having three or more births, increased the risk of gallstones by more than five times followed by having rapid weight loss, being single, having familial history of gallstones, and consuming high total energy." So, okay, there's some eating behavior stuff in there, but it's the fifth best predictor. And then the best predictor turns out to be having three or more kids.
Part of the problem here is, first of all, it's just really easy to do obesity studies, because the data is available. Then you can ask people like, "How tall are you, how much do you weigh?" Okay, boom data point. And then you can link that to whatever health outcomes they have. But it's much harder to get a broad picture of the predictors of a disease in a more qualitative way. This is a small study. It's only in Iran. I'm not going to say that like, "Oh, it's actually births that are predicting this better than anything else," because I think that would be just as shallow as saying it's like a cost of obesity. But also, I don't think the data supports the conclusion that if there were no fat people. We would save half of our healthcare spending on gallbladder cancer every year. I didn't look into the other 22 conditions and costs on this list. But to me, this whole exercise feels as superficial as saying, "Well, if everybody who lives in Mississippi moved to Massachusetts, they would all live 10 years longer."
Michael: Because, hey, there's a correlation. We know about the life expectancies. So, obviously, we know how to fix it. And that's not how correlations work, and that's not how health conditions work, and that's not how people work.
Aubrey: I think most people, who see and experience these statistics take them passively as just like, "That's just concrete information."
Aubrey: Don't think of it as a question of like, "Who's the person you want to be? Do you want to be the person, who's telling people who have cancer? You did it to yourself and now, I have to pay for it."
Aubrey: Is that the guy you want to be in the world?
Michael: I'm paying for your stuff?
Aubrey: Okay, and also, not really.
Michael: But then, Aubrey, that was the sound evidence footing part of this section.
Aubrey: Oh, no.
Michael: That was the direct cost, gallstones, back pain, whatever. At least, there's an actual cost there. The other component of these estimates is indirect costs.
Michael: This is where we get into the shit about lost productivity.
Michael: Some of these studies include lower wages.
Aubrey: We pay you less and now that's a cost we shoulder?
Michael: That's fucking ghoulish, dude. To be like you earn less money, therefore I'm paying extra for you.
Aubrey: That's astonishing garbage.
Michael: One of these studies I found also, because there's like absenteeism that people lose X number of days a year of work due to their health condition, like, that's part of the cost. But the problem with fat people is that, there's no evidence that fat people miss more work than thin people. One of the studies I found, the disappointment is palpable. They're like, "Oh, yeah, we can't actually count up last days of work due to obesity." So, they count fucking presenteeism.
Aubrey: Wait, what? They count when you're there as a cost?
Michael: You are just hanging out at work, I guess. [laughs] I don't know what fucking survey this was. But I guess fat people are some percentage more likely to admit to being presentiest at work. That's considered a cost of obesity. Try to devise something that I am less interested in.
Michael: Corporations are spending money on people, who go to work and don't work. That sounds like a company problem. That's not my problem as like a member of society. I don't care.
Aubrey: How do they even determine this? Because to my ears, what that sounds it is the findings of our study are fat people are lazy, which I'm like, "That's not a finding. That's a stereotype.
Michael: Yeah, exactly.
Aubrey: I'm not here for passively accepting that data.
Michael: Also, think about, I could sit down and I could make a cost of thinness. How many tens of millions of dollars do we spend on weight loss? How much loss productivity is there when somebody is in the throes of an eating disorder? Think you could easily do some try hard index about the cost of thinness to America. But that doesn't really mean anything. None of us actually think in this way. Some of these studies include fucking transportation costs that jets have to use more fuel, because they have more fat passengers now.
Aubrey: Are you fucking kidding me?
Michael: It's like, "Fuck off." I don't care. If United Airlines now has 3% higher fuel costs than it did in 1970, fucking first class seats are bigger. What's the cost of rich people on airplanes? I don't care about this stuff. What are we talking about here?
Aubrey: I will say, my dad was a pilot for United. It's very funny to me that you mentioned United in particular. He was a pilot and a Union Steward for United. Just as you said that, I just heard his voice ringing in my ears, which was like, "Oh, so, now, they're treating their customers like they treat their employees." It's just so [laughs] fucking mad. So mad. Yeah, I feel what he would say is, generally speaking, airlines are doing fine.
Michael: It's also even in the direct healthcare spending, when you look into it, there's actually, basically no difference between fat people and thin people, and things like the time they spent as doctors, the number of surgeries they have. Almost all of the actual difference in costs between fat people and thin people is prescription drugs. Fat people are more likely to be taking statins, they're more likely to be taking metformin for diabetes. The obvious solution to that would be to make the prescription drugs cheaper.
Michael: But that's not what anyone is actually talking about. These paragraphs of like, "Obesity cost the US healthcare system a billion a year." That never leads to therefore everybody should get medical coverage and we should make prescription drugs free. It leads to "Everybody should lose weight."
Aubrey: All roads lead back to, we actually need universal healthcare and that is a thorny, hairy, challenging problem that nobody fucking wants to take on and it is way the fuck easier to just be like, "Fat people cost so much money. Let's be mad at them about it" rather than being like, "Okay, let's get together another strategy on this issue that never dies."
Michael: Yes, fewer salty paragraphs about fat people. More salty paragraphs about health insurance companies.
Aubrey: Oh, okay. [laughs]
Michael: Okay. Do you want to read the next paragraph of the big old brick of text that I sent you.
Aubrey: "Three of every five Americans are overweight. One of every five is obese. The disease formerly known as adult-onset diabetes has had to be renamed type 2 diabetes, since it now occurs so frequently in children."
Michael: Have you heard this claim before about renaming type 2 diabetes?
Michael: I've come across this everywhere. I almost didn't look this up.
Michael: When you hear something 10 times, it's in your brain, and you're like, "Well, obviously, that's true." I wouldn't have read that in all these independent places if it wasn't true. The last thing we talked about the $90 billion cost of obesity, whatever, it's that's arguable you could say that it's true in some sense, even though it's not really very meaningful. This one is just a fucking lie. They did not rename adult-onset diabetes as type 2 because there's so many fat kids.
Aubrey: But they did rename it, yeah?
Michael: Yeah, they did rename it. Yes.
Aubrey: What prompted the renaming?
Michael: Okay. How familiar are you with the difference between type 1 and type 2 diabetes?
Aubrey: My understanding is that, type 1 diabetes is just like, your pancreas never worked and your body can't produce its own insulin. So, you need to inject insulin. And type 2 is your pancreas worked at some point, and then it burned out, and stopped working, and we don't totally know why. So, now, you need medication assistance, or you need to eat different foods, or pay different kinds of attention to the foods that you eat. In some cases, you may also need insulin.
Aubrey: Just to be really fucking clear. This is a thing that people love to say like, "Type 1 diabetes is like real diabetes and type 2 diabetes should just be called like you did it to yourself?"
Michael: Oh, yeah.
Aubrey: A couple of things for people to know. One, eating sugar does not give you diabetes. We don't know what causes diabetes, type 1 or type 2. Thing two is, there is not really evidence that it's something that people "do to themselves" and there's a little bit of evidence that shows that actually weight gain might be the result of getting diabetes, not the other way around.
Aubrey: It's just this weird moment, where everybody's walking around, all of these people who do not have this incredibly complex, misunderstood chronic health condition are walking around like they own the place and they know everything about how not to get this chronic health condition. They know everything about how to treat it and prevent it. And honestly, most of the advice that people give and get around this is garbage, and it doesn't fucking work, and it bears no resemblance to any existing science.
Michael: Exactly. All of this stigmatizing language in one dimensional rhetoric around diabetes evaporates the second you understand anything about the condition and its history. Basically, when you eat food, your body breaks it down into a form of sugar, and the sugar goes into your blood, and then your pancreas pumps out insulin to tell your cells to absorb the sugar. That's how they get their little foods. Type 1 diabetes is an autoimmune condition that basically shuts down your pancreas, so you can't produce insulin and type 2 diabetes is either you're not producing insulin or your cells aren't getting the message from the insulin. This is why they call it insulin resistance that your body is producing insulin, but the cells aren't opening up and taking in the sugar. These are very different things because one of them happens mostly in children. It happens when you're extremely young, if you have type 1 diabetes and type 2 diabetes, mostly occurs in people over 40 years old.
Michael: The first identification of the difference between these two forms of diabetes was in 500 BC in India. The test for diabetes was they would have pee on the ground and if the ants crawled toward your pee, because pee is sugary, then you had diabetes and if they didn't, then you didn't have diabetes.
Aubrey: You're spilling sugar into your urine is-- [crosstalk]
Michael: Yeah, very literally.
Michael: We've known the difference between type 1 and type 2 diabetes, since we've known about diabetes, basically. But essentially, we didn't really have a clear understanding. We didn't know what insulin was until very recently. We didn't understand the actual mechanisms. People call them a million different things. One of the terms was quick and thin diabetes versus fat and slow diabetes. That's what they said in the 1800.
Michael: Not great.
Michael: They also used to talk about hereditary diabetes versus sedentary diabetes, insulin dependent versus non-insulin dependent. There're a million different terms floating around for these two forms of diabetes. As medical science matures, it becomes clear that this is not a good way to talk about these two forms, partly because people are talking at this time about juvenile-onset and mature-onset diabetes. But people can also get type 1 diabetes later in their life. So, this autoimmune condition that causes your pancreas not to produce insulin, people just get that in their 30s and 40s sometimes.
Michael: It's basically just a total jungle around what are we calling these two forms. As early as the 1950s, people just started calling them type 1 and type 2 because we don't know what the fuck we're doing. None of this is working. Let's just say type 1 and type 2 because they don't contain any actual information about who is getting it and when. These terms started coming into use and you can actually look on Google Scholar, which is how I found this. For old papers, they're mostly an international development. People going to Africa and identifying like type 1 and type 2 diabetes cases there. This bounces around in the 1950s.
And then there's this period where all of the terms are around. Type 1 and type 2 exist, but also juvenile onset and then the super stigmatizing bad terms, all of this stuff exists, but it just different fields use different terms, different people use different terms, and then in 1976, a researcher named Andrew Cudworth identifies the actual genetic marker of type 1 diabetes.
Michael: He's the one that proves that this has a hereditary component. Andrew Cudworth writes a paper basically resurrecting this type 1, type 2 distinction, where he's like, "It really just doesn't make sense to talk about this as juvenile onset and adult onset, when one of them is an autoimmune condition and the other one isn't, and we don't really know what causes it. None of these terms are just very accurate."
Aubrey: Yeah. I think a lot of people have a lot of ideas about who gets type 2 diabetes and you just think of it as after you get to a certain level of fatness, then you just become diabetic, and it's a fait accompli, like, it's just happening. That's just categorically not true. Again, there are thin people who are type 2 diabetics. Tom Hanks has type 2 diabetes.
Aubrey: We love to think about this set of health conditions, diabetes, hypertension, all of that stuff that we associate with fatness as some fucking morality play.
Michael: There's also the thing of, this is something I learned from interviewing so many fat people over the years is like, what if 100% of cases of type 2 diabetes are fat people, who eat too much and are too lazy. Okay, do those people deserve employment? Do those people deserve medical care? The minute you start actually thinking about it, it's like, "Well, if everything you're saying is true, we're still not in a good place with this issue."
Michael: But then another thing that drives me nuts about the story, this is decades before we have any panic about childhood obesity. Obesity rates don't start rising really in earnest until the 1980s. The panic over childhood obesity is a mid-2000s thing. This is taking place in the mid-1970s. I've attempted to read some of the papers that Andrew Cudworth wrote about this and they're extremely technical. It's like, this receptor on the HB2 tendril or whatever, these are scientists having debates about the nomenclature of something within their field. At no point in any of these papers, just like there's too many fat kids, so we have to rename diabetes comes up. Basically, in 1979, the American Diabetes Association officially recognizes this type 1, type 2 thing and he's like, "Yeah, this is the way forward." And then the WHO recognizes it in 1980. That's how all that happened.
This whole thing of like, "Oh, they had to rename it." Not only is it not true, this is in the Wikipedia entry for the history of diabetes. This is not some secret hidden figures, untold history of diabetes. This is extremely mainstream stuff and yet this claim shows up everywhere. It's the same thing with a 90 billion number. It's just like, "I just need a sentence in this man." We all know obesity is really bad and all the kids are dying. So, I just need to throw in something. And you don't even do the most basic fact checking of any of the claims that end up in your article. That's how these zombie statistics run around. Anyway, annoyed.
Aubrey: Annoyed as fuck.
Michael: Next paragraph.
Aubrey: Okay, hang on. A recent study in the Journal of the American Medical Association predicts that a child born in 2000 has a one in three chance of developing diabetes. An African-American child's chances are two in five.
Michael: This was actually the one that got me interested in doing the research, because I was like, "That doesn't pass the smell test for me."
Michael: First of all, that's a weird roundabout way of just saying like how many people in America have diabetes?
Aubrey: It's weird. Yeah.
Michael: The prevalence rate of diabetes in the US, I've seen various estimates. It's somewhere between 7% and 12% of Americans have diabetes.
Michael: People born now have a one in three chance of getting a disease that only utmost 12% of people have. This comes from a 2003 article called the lifetime risk for diabetes in the United States and it's one of these studies that we've talked about a lot. It's a big old cohort study. They have hundreds of thousands of people, and they ask them the same questions, the same battery of questions every year, and then at the end, they tally what these are the correlations, dah, dah, dah. There's a survey question in this cohort study that says, "Have you ever been told by a doctor other than during pregnancy that you have diabetes or sugar diabetes?" I don't know what the second one is.
Aubrey: I don't know what that is either.
Michael: That's weird. They have 356,000 respondents and they get 14,000 yes answers. 4% of their respondents said, yes, I have been diagnosed with diabetes at some point. 4%. And then from this, they do a bunch of statistical mumbo jumbo, and they come up with a 33% chance for men and 39% chance for women of being diagnosed with diabetes at some point in their life. It's a projection of the future. It's being written in 2003 and it's about kids born in 2000. But read the sentence again.
Aubrey: A recent study in the Journal of the American Medical Association predicts that a child born in 2000 has a one in three chance of developing diabetes. Boy, I missed that predicts.
Aubrey: I missed the, we're looking into a scientific crystal ball part.
Michael: Also, when it says, a child born in 2000 has a chance of developing diabetes, don't you think childhood diabetes?
Michael: This study is of lifetime risk. One of the findings that stuck out to me in this study is that, the mean age of diagnosis of diabetes is 57 years. In the study it says, "In the cohort of individuals born in 2000, we estimate that 0.88% of males and 1.1% of females will develop diabetes by age 20." So, your chances of getting diabetes by age 20 are around 1%.
Aubrey: Significantly less than the estimated prevalence of eating disorders at those ages.
Michael: Exactly. By age 40, your chances are somewhere between 4% and 7%. By age 60, your chances are somewhere between 18 and 20%. So, almost all of the risk is coming from people older than 60.
Aubrey: Well, and again, these are framed in a way that's pretty misleading, and again, relies on weight stigma, and panic about fat kids in order to carry the message forward. The message is a deeply stigmatizing one here.
Michael: Well, that's the thing. If what we're talking about is childhood diabetes, why wouldn't you just list the prevalence of childhood diabetes?
Michael: The only reason you would use this weird prediction is because you want a big scary number for people.
Aubrey: Yeah, exactly.
Michael: There's also the thing that, if what we're really talking about is people over 60 being diagnosed with diabetes, if you're born in 2000 by definition, by the time you're 60, it's 2060. There's also presumably some new treatments and technologies available. So, it's also this weird fear mongering about people being diagnosed in 60 years with diabetes.
Aubrey: Well, if you look at the advances in the last 60 years of the treatment and diagnosis of diabetes, things are totally different now than they were in 1960. That's good, that's good.
Michael: You're much less likely to die with diabetes now than you were in the 50s.
Michael: A lot of this stuff is just like we're all going to die and it just isn't true.
Aubrey: But we are all going to die.
Michael: Good point.
Aubrey: Mike, that is a ghoulish fucking thing to do is to say, "You're going to die and it's going to be your fault."
Michael: Right. But then also, what's so striking to me about this research is that, with all of the scare stories we've read about childhood diabetes and stuff, how much coverage have we actually gotten that engages with those actual kids, and their parents, and their needs? Childhood diabetes, it's a really complex phenomenon.
Michael: There's this huge paradigm shift happening. One of the things I read was talking about how most adults who get type 2 diabetes. There's a 10-year period where you have elevated A1c levels, but it hasn't become full blown diabetes yet and it takes a really long time for that to get to where you cross a threshold for diabetes. But then in children that process takes roughly two years.
Aubrey: Oh, wow. So, it happens fast.
Michael: The fact that it has doubled in the last 15 years, I think is the genuinely, it's a thing, but it has increased almost exclusively with non-white kids. 75% of the kids, who are diagnosed with type 2 diabetes have a close family member who has it. This is an excerpt from a really interesting article about the paradigm shift around childhood diabetes. It says, "Support for the role of epigenetic factors comes from studies in children born to mothers, who had undergone bariatric surgery. Children, who were born before their mothers had weight loss surgery had a higher rate of obesity and insulin resistance than their siblings born to the same mothers after they had lost weight. Similarly, offspring of mothers with gestational diabetes have a higher risk of developing obesity and type 2 diabetes compared to offspring of the same mothers born after an earlier pregnancy not yet complicated by gestational diabetes. The other side of the coin, represented by studies in offspring of mothers exposed to famine also clearly shows the increased incidence of insulin resistance and type 2 diabetes later in life." So, there's something more complicated going on.
Aubrey: Well, this is also like we talked about this a little bit in our eating disorders episode with Erin Harrop that there is this burgeoning field of epigenetic research into what's the relationship between family or community traumas, and food security, and your body weight, or your disordered eating, or whatever. This is like this huge field that is opening up and there is more and more research coming out that actually things that happened to previous generations of your ancestors can directly impact your own health outcomes. Again, this is one of those places where it just feels people are walking around with this completely unearned certainty that we just reach for it and we go, "Great, you did it to yourself. You're going to die. That's all I need. All I need to know is that you're doing the wrong thing and I'm doing the right thing."
Michael: Reading the actual literature on this, which to my great discredit was the first time I had actually engaged with it was just like, "Oh, this is so much more complex than it seems" and it has never been presented to me in any of these magazine articles or whatever as an actual complex problem that needs complex solutions. You can see the way that it's just used as this cudgel. It's like, "If kids don't do this, they're going to be diabetic or America spends this much on diabetic people." It's not fair to just treat this as one dashed off sentence in your article about obesity, and then be like, "Oh, those kids need to be smaller or whatever." It's like, "No, they probably just need us to help them in much more tangible ways."
Aubrey: Well, there's also just way more going on here I think there are these times when our public discourse, people who are not disabled, people who are not fat will talk about being, "I'm just concerned. I just want to solve this problem." But then their actions tell on them, because their actions are not geared towards solving a problem. Their actions are geared toward freaking people the fuck out. If you are concerned about something, if you want to solve a problem, we all know what that looks like. You approach it with a great deal of tenderness, you approach it with a great deal of curiosity, you try and figure out what are the-- You test your own assumptions. The ways that we talk about fat people's perceived health risks, the ways that we talk about diabetes, and hypertension, and heart disease are not those ways.
Aubrey: These kids are all going to get diabetes and it's going to cost us $90 billion dollars. That's not solutions oriented, that's not loving, it's not caring. Fat people deserve better than that, diabetic people deserve better than that. It is such shitty lip service that does the opposite of what it says it's doing.
Michael: Those people deserve a farmers' market [crosstalk]
Michael: [crosstalk] to offer according to the rest of this book.
Aubrey: I don't know how many times I can fire you, but once again, Michael, you're fired.
Michael: Okay. I want you to do the last one.
Aubrey: Last sentence of this weird, terrible paragraph.
Aubrey: "Because of diabetes and all the other health problems that accompany obesity, today's children may turn out to be the first generation of Americans, whose life expectancy will actually be shorter than that of their parents." I hate this phrase. I have heard it so many times.
Michael: This is king of the zombies. This is the Zombie Lord.
Aubrey: This is one of those things, where there is so much fucking stigma placed on parents of fat kids. We have this really intense cultural lens that is like, "If a kid is fat that is the result of a failing of a parent."
Aubrey: And this feels like the gnarliest and most ghoulish way to address a parent. It's like you're killing your kid.
Michael: Yeah, it's absurd. Do you know who Dr. William Clish is?
Michael: He's considered one of the fathers of bariatric surgery.
Michael: He was the head or something on the American Board of Pediatrics. He was the past president of the North American Society for Pediatric Gastroenterology and Nutrition, trying to look up on Wikipedia, and most importantly for us, he was the doctor in Supersize Me that counseled Morgan Spurlock.
Michael: You know this man, you know his work.
Aubrey: I do.
Michael: In 2002, he gave an interview to the Houston Chronicle. He's talking about childhood obesity. He says, "If we don't get this epidemic in check for the first time in a century, children will be looking forward to a shorter life expectancy than their parents."
Aubrey: This is our patient zero. This is the first use.
Michael: This is it. Yes. And then it gets picked up by the Surgeon General in 2004.
Aubrey: Oh, God.
Michael: It's ending up in these reports, and then it ends up in a speech by Bill Clinton, and then it's often running. The only group, this bugs the shit out of me. The only group that has ever actually contacted William Clish to find out where he got this claim is the Center for Consumer Freedom-
Michael: -which we are talking about before. It's a clear front group for Coca-Cola, and McDonald's, and Monsanto, and all of these other horrible food corporations. I feel super weird and gross about citing their work, but in all of the times that this claim has been repeated in popular media, nobody it appears other than these corporate lobbying ghouls have ever reached out to this guy to be like, "Where did you get this?" According to the Center for Consumer Freedom, he says, he based it on intuition.
Aubrey: Are you fucking kidding me, Michael?
Michael: Literally, the dude made it up. And then as this is bouncing around everywhere, people try to substantiate it.
Aubrey: Because people fucking want it to be true. God damn it.
Michael: Exactly. In 2005, you get a paper in JAMA called a potential decline in life expectancy in the United States in the 21st century that goes through this whole history where it's like, American life expectancy has increased significantly, steadily for the last one hundred years. Infant mortality has fallen, after World War II, we get antibiotics. It used to be roughly a third of Americans were dying of infectious diseases. They get the flu or pneumonia, these things. This is one of the great successes of humanity of the 20th century. Huge deal, steadily increasing life expectancy. But then all this panic about obesity and how obesity is going to be the first generation of kids to die and their parents, whatever, all of this comes from the fact that the rates of growth in life expectancy have started to slow.
Aubrey: Oh, my God.
Michael: That's all they have.
Aubrey: We're living longer, but at a less dramatic, longer rate?
Michael: Progress is slowing down. This is happening in the late 1990s. They do all of the whole thing again is just empty statistical mumbo jumbo. The whole thing is like, "What would happen if everyone in the country who had an overweight or obese BMI instantly, magically attained a BMI of 24?" That's what they're basing this whole thing on.
Aubrey: Oh, my God. So, we're now just fully in fantasyland, yes?
Michael: Yeah. These conditions where every single American is under a BMI of 24 have literally never existed in the country.
Aubrey: Right. As it turns out, fat people are around, have been around, will continue to be around.
Michael: Fat people have existed and also exist. This is a sidenote, but it also does this thing, where it just mentions that the BMI doesn't work for black people. It's doing all this like, mortality rates, BMI, and then it's like, "Oh, yeah, anyway, BMI isn't connected the mortality rates for black people. Any black person above 60, it just doesn't really work for them." Anyway, [laughs] I'm just like keep going.
Aubrey: Just toss it off, like, flip.
Michael: All right, good thing, we're not using the BMI like a marker of health in every single doctor's office in the country, then.
Michael: We'd really be in trouble if that was true, anyway.
Aubrey: Neat and cool.
Michael: This leads to the conclusion. Assuming the current rates of death associated with obesity remain constant in this century, the overall effect of obesity in the United States is a reduction in life expectancy of one-third to three-fourths of a year.
Michael: That's a tiny effect. And also, they're not saying that life expectancy will shorten by that much. In 2005, the life expectancy is around 77. They're basically saying, "If it wasn't for all the fat people, American life expectancy would be 77.5. That's what we're talking about.
Aubrey: God damn it.
Michael: In a hypothetical scenario that has never existed in the United States, our life expectancy would be around half a year longer.
Aubrey: Oh, it's just so irritating.
Michael: This isn't even the original claim that was made. The original claim that was made was that this generation of children, people born now are going to have shorter life expectancies than their parents. That's not what this is showing. It's showing that rates are going to continue to increase, but they would have increased more if it wasn't for obesity.
Aubrey: My God.
Michael: The first part of that sentence is also important where it says, "Assuming that current rates of death associated with obesity remain constant in this century, it's going to affect life expectancy."
Michael: But why would we assume that current rates of death associated with obesity would remain constant? Deaths associated with obesity have fallen precipitously. You are significantly less likely to die of a heart attack now than you were in 1950. Even cancer, I found a really interesting analysis of this, like, changing mortality statistics in America. Since 2011, since very recently, cancer death rates are down 20%, heart disease death rates are down 10%.
Aubrey: Yeah, and also, again these are all presumed to be causes of death that are related to being fat. And that also hasn't been fucking established.
Aubrey: It has never been established. We're going so far down the road without the most basic thing confirmed. It's just a house built on a foundation of sand.
Michael: Right. It drives me nuts. It is the same researcher who wrote this paper being like, "Oh, we're all going to die. Life expectancy getting shorter." He writes another paper in 2009 that is completely unrelated to this. It's Social Security Administration projections. A million institutions project US life expectancy for various things, where he predicts that the Social Security Administration and the CDC's life expectancy predictions are not optimistic enough. He says life expectancy for Americans is going to keep increasing and it's probably going to be 87 years by 2050.
Michael: Oh, so, when you're not writing about obesity, you're going to be like, "Oh, well, actually, this is what the data indicates. But I had to write an article that was scaring people about obesity. I did some weird statistical show with that." You find this all over the place. You find this with some of the economic analyses, too, that when they're writing for an obesity audience or for a Public Health Journal, that would be like, "Obesity is the biggest killer." And then you'll find the same author with a paper that has something to do with something completely else and they're like, "Oh, yeah, obesity is really not that big of a deal."
Aubrey: It's a social imperative, not a fucking scientific or medical one.
Michael: Exactly. They want to raise the alarm about obesity. It's like, "Oh, it's a public health problem. We have to do something about it." But you're not really being transparent about the fact that that's what you're doing. The same author, he admits in this paper, he's like, "Oh, yeah, I wrote another paper a couple years ago saying that obesity might shorten lifespan, but that was only if we do nothing. My actual projections for life expectancy in 2050, I'm just assuming that the reductions in the death rates are going to continue. I didn't do that in that previous paper."
Aubrey: Good God.
Michael: It's this totally counterfeit, statistically, even the people putting out like, don't really believe in it.
Aubrey: I'm so frustrated by all of it, Michael.
Michael: There's this thing of American life expectancy is actually decreasing now, but the decreases are almost all in middle aged white people and it's almost all because of drug overdoses. It's 70,000, overdoses a year. Opioids.
Aubrey: Jesus, Christmas.
Michael: There's also a lot of liver cirrhosis and stuff. And even in these papers about white people are dying younger. They're like, "Yeah, we looked into obesity and yeah, we just don't see it."
Aubrey: It's just wild how often you sort of read stuff and just on the face of it as a layperson, it just doesn't hold water. you know?
Michael: This is what really bugs me about this is that, you expect the Michael Pollan's of the world journalists to do this kind of thing, whenever. I'm trying to raise awareness, I need this paragraph in my story being like, "Here's a bunch of scary statistics about obesity." Whatever. We expect that from journalists. But what we see here is, there's a pipeline of academic institutions that are producing numbers for exactly this purpose. They are producing numbers, so that it can show up in the Surgeon General's report, it can show up in media reports, it can go on the CDC website, whatever to raise awareness of this, what they perceive to be a public health problem. I think on some level, I get it. If you're a smoking tobacco researcher, if you're a climate change researcher, I get that you want to get science out there in a way that is going to inspire people to take action.
But the problem is, I think that this has gotten away from people, that they've forgotten how many assumptions they're making, they've forgotten how thin this correlation stuff is, and they've forgotten that the purpose of all of this. If all of this raising awareness, all of this is supposed to be for public health, it's supposed to make people healthier. What we see again and again in these studies and the way that these studies are covered in the media is that, we're giving up on public health, so, we can warn people about obesity.
Aubrey: Or, giving up on public health, so that we can call people fat and be like, "It's your own fault. You're gross. I think you're gross, and it's your own fault, and you're going to die, and that's also your own fault."
Aubrey: We are giving all of this up for what is essentially emotional satisfaction. It is a project that is designed to make thin people feel better about their health by using fat people as a morality tale.
Michael: Right. I also think it allows public health institutions to find one of the few things for which there is a case for personal responsibility or something that they see as an individual change, something that they can do something about. What I found in a lot of the research that I read for this was public health having an existential crisis over the last 40 years, a lot of our public health institutions are set up for communicable diseases. They're set up for things like, "Okay, there's a Legionnaires disease outbreak at some hotel in Michigan and we got to fly a bunch of people out there, we got to isolate, we got to do contact tracing, we got to figure this out, tamp it down." Something acute.
Whereas public health institutions, when it comes to non-communicable diseases, a lot of these institutions are really flailing, because there isn't a lot that they have in their power to do. A lot of this stuff comes down to weird, esoteric shit, like, urban policy, and housing policy, and welfare, tax policy, and all kinds of other stuff. Because a lot of these diseases are actually diseases of inequality. As you said last episode, this gets very political very fast and I don't think that Institutions of Public Health and institutions of science and medicine, they're not set up to do these more holistic analyses of problems.
I think that they have seized on obesity, because it's one of the few things that they feel they can control, even though they can't, because none of these interventions work. But it's one of these things where they feel like, "Oh, okay, we as a hospital can do a weight loss program or we as an institution can give people weight loss tips. We can give out nutritional guidelines, dietary tips for Americans." It allows them not to deal with these much thornier and much more difficult issues.
Aubrey: Yeah, it's so frustrating, because we get so attached to having these cultural conversations about health in a vacuum as if they are somehow uninfluenced by social, or political, or institutional dynamics. And actually, what the research shows and what the lived experience of marginalized people shows is that, our understandings of health are a direct result of those institutional, and cultural, and political factors that it is a pretty straight line between what our institutions decide to do and the health outcomes of any given population. It's frustrating to have so many conversations about this kind of stuff that are like, "No, no, no, I just want to talk about the science." It's like, "Buddy, you can't talk about the science without talking about the bias that is baked into the science. Sorry."
Aubrey: Also, what "the science is showing you," is that social issues play a really significant role in who has access to what kind of care and when. It's such a stubborn approach that we take.
Michael: Another way to put it is that, Institutions of Public Health need to disinvest from weight stigma and reinvest in brain.
Aubrey: Goddamn it, Michael.
Aubrey: We're going for a landmark, two firings in one episode.
Michael: I've been saving that for like 45 minutes.
Aubrey: Of course, you have.