The Body Mass Index

The BMI is EVERYWHERE. But is it scientific or scientif-ish? While many Americans think of the body mass index as an objective measure of health, its history reveals a more complicated story. This week, Mike and Aubrey tackle the first in a two-part series about the BMI and the “Obesity Epidemic.” Along the way they visit 18th century Belgium, learn a gross new acronym and dissect Dracula's facial features.

LINKS!:

• The Bizarre and Racist History of the BMI (Elemental) 
• Adolphe Quetelet, Social Physics, and the Average Men of Science, 1796-1874 (University of Pittsburgh Press)
• Mindful of eugenics’ dark history, researchers are reexamining the genetics of social mobility (Quartz) 
• Adolphe Quetelet (1796–1874)—the average man and indices of obesity (Nephrology Dialysis Transplantation)
• For Researchers on Obesity: Historical Review of Extra Body Weight Definitions (Obesity)
• Quetelet, Adolphe (Canada’s Eugenics Archives)
• Top 10 Reasons Why The BMI Is Bogus (NPR)
• The False Science Linking Body Shape to Personality (The Atlantic)
• Obesity task force linked to WHO takes “millions” from drug firms (The BMJ)
• Impact of weight bias and stigma on quality of care and outcomes for patients with obesity (Obesity Reviews) 

Transcript

[Maintenance Phase theme]

Aubrey: We're ready. I think you're up on intro, yeah? 

Mike: This one might be kind of offensive. [chuckles] 

Aubrey: [laughs] 

Mike: Sorry, in advance.

Aubrey: [laughs] 

Mike: Welcome to Maintenance Phase, the podcast that is just right between 20 and 25, too long to 25 and 30, and morbidly too long from 30 to 35. 

Aubrey: Oh, God. I just want to make the tagline of our podcast, just permanently, the podcast that is morbidly too long. 

Mike: [laughs] When you apply morbidly to anything else, you see how shitty it is-- [crosstalk]  

Aubrey: Yeah. Describe another person as morbidly anything and see how that goes.

[laughter] 

Aubrey: That’s not going to be great. 

Mike: I am Michael Hobbes. 

Aubrey: I'm Aubrey Gordon. 

Mike: And if you want to support the show, we are on Patreon at patreon.com/maintenancephase, where you can listen to our adorable bonus episodes about things like Meghan and Harry and The Bachelor, or you can buy t-shirts, or just give us money for no reason, or do none of that, and just continue listening quietly. 

Aubrey: That's right. Today, Mike, we are going to talk about the body mass index, better known as the BMI.

Mike: Dude, I'm so excited. 

Aubrey: I am really excited too.

Mike: We did a whole episode on Bono stuff, and now, we're doing one on BMI stuff.

Aubrey: BMI. [laughs] I am curious, Mike, what kind of role would you say the BMI has played in your life? How does it show up for you? 

Mike: Oh, man. As a guy who presents as “normal” on the BMI, I think it doesn't play much of a role at all. I actually went to the doctor's office a couple of months ago, and they asked to weigh me, and I was like, “I prefer not to be weighed.” I was ready to have a big fight about it, be like, “This is ridiculous. It's not related to health,” blah, blah, blah. They were like, “Okay.” Hopefully, that means that doctors’ offices are becoming more chill about this, but I think it also means that like, “He's a thin guy, and we don't need to weigh him.” I think that's obviously playing into it too. 

Aubrey: Right. It only applies to bodies that we deem deviant in their size. Absolutely. 

Mike: And then, we start to care. 

Aubrey: Yep. And then, we start to care. That applies to underweight people, and it applies really, really prominently to people who are “overweight.” 

Mike: I hope we mostly focus on skinny shaming in this episode. I think somebody has to. 

Aubrey: Oh, God. You know it's my wheelhouse, Mike.

Mike: I know, you love it.

Aubrey: [laughs] 

Mike: It's your number one issue. 

Aubrey: The BMI is a simple calculation. It is your weight in kilograms divided by your height in meters squared. It doesn't measure muscle mass or body fat or build or age or anything else. It is truly just your weight divided by your height, the end. In many medical systems around the country and around the world, it has become central to accessing medical care. As we will learn today, its history is absolutely not as a tried-and-true medical tool.

Mike: Shocking twist. I've spent the last couple of weeks actually reading a bunch of books about race and IQ, and this whole nightmare of an academic field, and I don't know much about the history of the BMI, but I do think that basically, any scientific effort to boil a complex phenomenon, such as health or intelligence, down to one number is just pre-doomed. It's just always a bad idea. 

Aubrey: Well, and it's always a bad idea to try and boil all that stuff down into one measure. It's an extra fucking bad idea when we only ever put white people in charge, right? [laughs] 

Mike: Yeah.

Aubrey: Because what happens with the BMI, what happens with IQ tests, all of that stuff came to be in the 1800s and early 1900s, is that whether or not they said that that was what they were doing, what white people were functionally doing is looking for reasons to prove that we were “genetically superior.” 

Mike: Yes. I do think that if you come up with a system of ranking humans on their inherent worth, and you end up on the top of it. We just need to have a little bit more skepticism of any system that has that output. It's like me coming up with some sort of system of ranking how good all the names are in America. Like people named Jeff suck and people named David are just trash. Oops, people named Mike are just great. I came up with this objective system and everybody named Mike is cool. You'd be like, “Hmm, Mike, I don't know.” 

Aubrey: Right. Sorry, guys, I don't make the rules. I just absolutely make the rules.

Mike: All we're doing is science here, guys. [laughs] 

Aubrey: Oopsie-daisy. Yeah, that’s right. I actually wrote about the history of the BMI a couple years ago. You have talked about this piece. 

Mike: Yeah, I love the piece. 

Aubrey: Part of what's happened with that piece is that it's gotten very popular, which is wonderful, but it's also gone through the giant game of telephone that is the internet. 

Mike: Oh, no. 

Aubrey: When people talk about that piece now, they're like, “The inventor of the BMI was the head of the eugenics movement.” And I'm like, “No, he for sure wasn't.” People are so incensed at the history, which totally makes sense, but they start to ascribe intent to the history, that as we'll talk about just isn't really documented. That doesn't mean it wasn't there, but it isn't really documented anywhere. I actually think it's much more interesting and telling that what we have is a history full of people who didn't think they were doing anything discriminatory, and created one of the wildest, worst, and most ubiquitous pieces of science that we all hear about all the time. 

Mike: Yeah. Also, that can sound like a defense, like, “They were doing their best.” But if you want to prevent this from happening in the future, you do have to actually understand how it happened and getting into the nuances of it.

Aubrey: Totally. You and I are both white people, who think and talk about race in the course of our work. I think it's a really meaningful and instructive thing to look at this history where, again, all of these white people thought they were helping. I think it feels much more instructive to me as a white person to go, “You know what? Even when I think I'm helping, I might be hurting.” 

Mike: Yeah, exactly. 

Aubrey: Well, shall we dive on in? 

Mike: Let's do it. 

Aubrey: Okay. Our story begins in Ghent in 1796, we're in Belgium before it was Belgium. In 1796, in Ghent, this guy was born who was named Adolphe Quetelet.

Mike: Not a lot of Adolphes that we run around these days.

Aubrey: He was not a healthcare provider of any kind, not a medical researcher of any kind. His work otherwise did not revolve around the human body at all. It revolved way more around astronomy, and around statistics, and around analyzing state data. He's a guy who's very interested in describing the world as it is. He wants to figure out why the world works the way that it is and articulate that.

Mike: This is like Chekhov's scientist.

Aubrey: [laughs] 

Mike: [crosstalk] -establishing with this guy is not trying to do any harm. He's interested in describing the world and maybe coming up with some measurement systems.

Aubrey: Mike, I just really appreciate that anytime I try to structure a twist into a story, you're like, “No, I can tell what you're doing.” 

Mike: [laughs] Good guy scientist doing his best, I wonder what will happen. 

Aubrey: I think more than anything, he's described as a bureaucrat and a population analysis kind of guy. It is worth noting that his work happens against the backdrop of a major civil war that becomes the Belgian Revolution. What he wants to do, while Belgium is working toward its independence, is to put Belgium on the intellectual map. There's this sense amongst Belgian academics that the Enlightenment happened and passed them by. And so, Quetelet decides that he's going to be the guy.

Mike: Never underestimate the importance of dude insecurities. Maybe going a little too fast and cutting some corners.

Aubrey: So, he starts working on these really big swings academically. His biggest project is something that he called Social Physics. Is this something that you've heard about at all, Mike?

Mike: Social physics? No.

Aubrey: He's essentially looking at datasets and analyzing datasets about people, and is trying to look for social “laws” that mimic the laws of physics. 

Mike: Something like if you eat off of smaller plates, you'll eat 30% less, water type?

Aubrey: [laughs] His findings are actually better than Brian Wansink’s.

[laughter] 

Mike: Okay. Not saying much, but you know-- 

Aubrey: He writes quite a bit at this time about-- he wants to figure out how to measure acts of courage and heroism. He wants to measure acts of cowardice and malice and all of these different things. But he's one dude, and how the fuck do you measure courage at a population level? So, he doesn't have the infrastructure to pull all that off, so he starts analyzing state-gathered data sets. Those are things that are way more boring, frankly, like birth rates and death rates and marriages and height and weights, as it turns out.

This was all part for him of finding his idealized average man. That average man was defined mathematically absolutely as the center of a bell curve, no question, but it was also an ideal. In his mind, the average was what everyone should aspire to, and we should have more homogeneity, we should be more aspiring to normalcy. He actually says at one point, “If the average man were completely determined, we might consider him as the type of perfection and everything differing from his proportion or condition would constitute deformity or disease or monstrosity.”

Mike: What's the output of this? 

Aubrey: So, he finds stuff like death rates are highest in February. He starts looking at birth rates and figuring out when those are highest and lowest and stuff like that. What he's looking for, again, is some kind of pattern that's like, “Aha! Here's the secret key to understanding the human condition.” 

Mike: [whispers] Weird.

Aubrey: And that is what leads him to creation of what we later come to know as the BMI. He's trying to build the case for this idea of social physics, the laws of human behavior kind of stuff. And he's using whatever state-gathered data he can get his hands on, and one of those datasets his height and weight data from France and Scotland. Those datasets are made up exclusively of men, exclusively of white people. He analyzes this data, he plots it out, he finds the bell curve, and this whole process and the output of it is called Quetelet's index. 

He envisions the index being used by the state to help predict the size and shape of the population as a whole. He's actually very clear at the time that the BMI is not to be used for individual diagnosis or treatment or assessment. He's like, “This is a population level tool. Do not try to use it on individuals. It's not going to work. It doesn't make sense.” 

Mike: So, he basically has this index of the average French and Scottish person has this ratio between their height and their weight.

Aubrey: Yeah.

Mike: It's like plotting out the average length of people's arms to their average shoe size. It's like there's a ratio and it differs between people, whatever.

Aubrey: Totally. This was a footnote in his work around social physics at the time. It was not the main event. His work did generate controversy and did generate interest and debate. But it was not about the BMI, it was about social physics. A bunch of his contemporaries were like, “I don't like this because we have freewill. So, why would there be laws that govern human behavior? We govern human behavior. How dare you.” 

Mike: In their defense, it is a very dumb idea.

Aubrey: [laughs] 

Mike: It seems totally asinine.

Aubrey: Yeah, it's not great. 

Mike: It's not a worthwhile endeavor.

Aubrey: The trick here, this is where it gets like a little sticky. After he dies, his work gets picked up by some pretty unsavory characters. Mike, I'm going to ask if you're familiar with a movement called eugenics? 

Mike: Oh. A little bit familiar, especially after all my reading last couple weeks.

Aubrey: Yeah, totally. 

Mike: This is the idea that basically humans are like livestock, and that there are some humans that are superior to others, and we can basically make the human population more superior over time by encouraging breeding among the good ones and discouraging breeding among the bad ones. Eugenics refers to the bettering of the human population over time. And then, dysgenics is the opposite, is this idea that human societies are declining, because the stupid people and the racial minorities are procreating more than their social betters, is basically the theory, right?

Aubrey: Right. It's idiocracy. 

Mike: I feel compelled to point out that this is total fucking nonsense. Evolution does not happen on these timescales. It's a complete fallacy to think that since the 1950s higher birth rates among poor people mean anything. As a scientific endeavor, it's just complete trash. 

Aubrey: Also, it feels worth mentioning that it wasn't just the discouragement of procreation amongst “undesirable" groups of people. There were many, many state apparatuses focused on forced sterilization of people of color, of immigrants, of autistic people, of people with developmental disabilities, of sex workers. This is actually where we get the term 'moron.' It was an official range of IQ scores. If someone was declared legally to be a moron, they would be forcibly sterilized. 

Mike: Yeah, it's really bad. 

Aubrey: The thing to know about what happens with Quetelet’s work, is that it gets picked up by this guy, Francis Galton. Is that someone you've come across in your research? 

Mike: No.

Aubrey: Galton was sort of a leader in scientific racism. He was a major, major vocal proponent of eugenics. He was knighted for his contributions to the eugenics movement. 

Mike: Sir Eugenics.

[laughter] 

Aubrey: That's right. He's also a big believer in social Darwinism, which is perhaps unsurprising because do you want to know who his cousin was? Was it Charles Darwin? Yes, it was. 

Mike: So, Darwin has a problematic cousin, just like everybody else. 

Aubrey: Totally. There is a quote from Canada's Eugenics Archive where they point out Quetelet and Galton as key figures in this. They essentially say that Quetelet was looking for the average and labeled the average ideal, but Galton really took it to the next level. Here's what they say about that. 

“It was Galton who, while building upon Quetelet’s notion of the “average man,” a product of measurements and statistics effected an important twist. Instead of positing the normal as healthy and desirable, Galton equated the normal with the mediocre. Within this tradition, the normal state is to be transcended, improved upon, and overcome.” 

Mike: Sure. They're all just making stuff up without realizing that they're making stuff up. 

Aubrey: Yeah, it's all totally fucking made up. 

Mike: Because it's not clear that the average should be the ideal either. 

Aubrey: That's right. 

Mike: But it's also not clear that the average should be bad. They're just putting value judgments into this and calling it science. 

Aubrey: They do this again. Quetelet is also credited with founding what's was later called the positivist school of criminology. That's where we get shit like homo criminalis. Is this something you're familiar with, Mike? 

Mike: Dude, this comes up a lot in the race and IQ literature.

Aubrey: Tell me.

Mike: This is the idea that there are actual physical features of criminals, like inborn criminals. What I found out reading Stephen Jay Gould's The Mismeasure of Man, is that Count Dracula, in that book was specifically written to have the facial features of the born criminal.

Aubrey: What?

Mike: Yes. Like the high widow's peak, the long nose, the sharp cheekbones, all of that was at the time considered to be the criminological features. There was also this weird science about how born criminals don't blush.

Aubrey: [laughs] 

Mike: This is complete junk science. This is one of the things, like, “Oh, he doesn't blush, he must be a criminal.” Part of that might be wrapped up in Dracula being cold blooded or whatever. 

Aubrey: Well, also part of that is such a measure of white people?

Mike: Yes, exactly. 

Aubrey: Like, “I'm constitutionally incapable of committing a crime because all I do is blush. Try again, jokers.” It's not great. 

Mike: It's not good. 

Aubrey: This one branch off of Quetelet’s work is being used as a justification for eugenics. 

Mike: How is the BMI related to all of this? These forced sterilizations, are they being done on a BMI basis? 

Aubrey: Not that I found, but it is this idea that is a wave that is started by Quetelet, which is the idea of, "What does a normal person look like?", gets immediately transferred over within a couple of decades of his death into, "If we can know what normal looks like, we can know what exceptional looks like, and we can only be exceptional people." And that means white and wealthy and not disabled, and all of these sorts of things. This project of social physics starts to inform all kinds of systems, in a way that is disconnected from what he thought it was going to do. 

Mike: BMI isn't officially a justification for eugenics, but eugenics is the context in which the BMI is gaining more notice. 

Aubrey: Absolutely. The other context in which it's gaining more notice is through insurance companies. 

Mike: Oh, right. 

Aubrey: In 1842, Quetelet creates Quetelet’s index, later called the BMI. By 1867, so still within his lifetime, the first American Life Insurance Company creates height and weight tables for the purposes of charging fat policyholders more. 

Mike: Interesting.

Aubrey: Again, this is 25 years after Quetelet creates the BMI. This idea of “normalized" body starts to be used for corporate profit, which will be a through line in the story. A bunch of different insurance companies create a bunch of different tables. And then, the industry as a whole realizes that they should probably standardize them. The first newly aligned insurance table that's used by multiple companies is the MetLife table, which was introduced in 1942. So, it really does take them quite a bit of time to get there. 

Mike: So, this whole time, they're using Quetelet’s data on French and Scottish people? That's still the measurement that they're using?

Aubrey: No. They are making up their own measurements. 

Mike: Oh.

Aubrey: They have taken the idea that there is a correct weight for people to be, and they're like, “We think it's this.” Each different insurance company is fully making up what they think the correct weight is. Sometimes, they are broken out by age. Sometimes, they're broken up by gender. Sometimes, they're broken out by something called frame size, small frame or a large frame. They don't account for age, they don't account for race or ethnicity or disability or health conditions or any of that kind of stuff. 

Mike: I might be overweight on the MetLife version, but I might be normal on the Quetelet version? 

Aubrey: Yeah. I looked at some of these charts and there is genuinely a 40-pound difference in some of the-- [laughs] 

Mike: Oh, wow.

Aubrey: It's really significant differences. The data that they're using here is super-duper all over the place. They're drawing their examples from their own pools of policyholders. So, they're basing all of these charts on the height and weight of people with the wealth and inclination to buy life insurance policies, which once again means, at this point, in 1942, that is white men, everybody. A bunch of their data is also self-reported. Some of the weigh-ins that they use for these charts include people like wearing their clothes and shoes, and some of them don't, it's a total mess. That's in the 40s. 

These insurance charts keep floating around. Some doctors actually start to use the insurance charts as guidelines for their individual patients, which is truly fucking wild to me, because, again, insurance companies are staffed by actuaries. They're not staffed by doctors. They're not staffed by anyone, sort of healthcare, individual care provision experience. And it makes its way into doctor's office is enough, that there becomes this desire for a unified system across doctors, in the same way that insurance companies have developed a unified system for insurance companies. 

The person who decides to take on this challenge of finding the standardized system is our old pal, Ancel Keys.

Mike: Ah, here we go. 

Aubrey: He really was as close as they had at the time to a celebrity researcher. He's on the cover of Time Magazine. He's responsible for military K-rations. He's responsible for the Minnesota Starvation Study. He's also a big part of-- if you would like to know about the history of the low-fat diet, please go back and listen to our episode on SnackWell’s. He's all over that business. He has called fatness and fat people disgusting, a hazard to health and “ethically repugnant.” Sorry for my unethical body, everybody. 

Mike: In his infamous Newsweek cover story, he talks about people eating themselves to death.

Aubrey: I spared myself reading that piece for this. [chuckles] Now, I'm very glad that I did. 

Mike: Yeah. 

Aubrey: Ancel Keys starts looking for ways to effectively measure body fat. He's not looking for the best way to measure and most accurate way to measure body fat. He's looking for the most cost-effective way for doctors to do this in their offices and healthcare providers to do this in their offices, which is a different question. 

Mike: He's also somebody we've established is not a neutral arbiter of this. He's clearly somebody who thinks that fatness is a crisis, and that fat in the diet is a crisis. 

Aubrey: Yes, absolutely. 

Mike: Those are the two beliefs that he's coming into this project with. 

Aubrey: He conducts a study of 7500 men from five different countries. He tests three methods for measuring body fat. These are the three most common at the time. One is water displacement, where they fully just submerge you in a tank of water and see how much water you've displaced, and that's how much body fat you have. Great. Another one is skinfold tests, which is where they get out those big calipers and measure the skinfolds. 

Mike: It's better to reserve those for children in front of all of their peers. 

Aubrey: [laughs] 

Mike: Let’s not do that in doctors’ offices. 

Aubrey: Yeah, that's right. Like Quetelet, he draws his subjects from predominantly white nations. He's drawing subjects from the US, from Finland, from Italy. And he's also drawing them from Japan and South Africa. He does note this in the study that while he had participation in South Africa from Bantu men, so men from the Bantu tribe, it was not a representative sample. He's technically including black people in the study, but not using any of the data in his analysis or recommendations.

Mike: Basically, it's there but ignore it. 

Aubrey: Yeah, exactly. Once again, he's centering white people, he's centering wealth, and it's only men. Only men here. He is pretty circumspect about his findings in this actual study. He says, “Again, the body mass index proves to be, if not fully satisfactory, at least as good as any other relative weight index as an indicator of relative obesity. Still, if density is truly and closely inversely proportional to body fatness, not more than half of the total variance of body fatness is accounted for by the regression of fatness on the body mass index.” Basically, what he's saying is the BMI is the strongest of three weak and imperfect measures and it's right about half of the time.

Mike: Like the other methods, if you're putting somebody into a bathtub and figuring out how much water they displace, that's just measuring how big they are. They might be a super-duper buff person--

Aubrey: Right. The Rock. 

Mike: They're all pretty bad. 

Aubrey: Totally. As we're looking at this understanding of the BMI as some kind of hard and fast medical truth, this is happening in the 70s. We're in the last 50 years, when this really gets introduced as an individual medical diagnostic tool. It just is fascinating to me that, "It's right about half of the time, so it's the best we've got, so let's run with it." It's also worth noting that those numbers hold fast. There was a study in 2011 that found the same thing. It predicts obesity about half the time. [laughs] 

Mike: There's also this thing, where I feel a lot of these kinds of methodologies, people will write papers, documenting them and proposing these as methodologies and be like, “Well, obviously, there's weaknesses, and obviously, no one's going to run with this.” 

Aubrey: Yeah, totally. Then it's like, “Surprise!” 

Mike: Yeah. It's like, “No one's going to use this for individuals clearly.” And then, people are seeing and they're like, “A number? Let's use that.” 

[laughter] 

Aubrey: I like this one. There's a chart. 

Mike: Yes. And all of these caveats get completely erased. 

Aubrey: Within a few years of this finding from Keys, the National Institutes of Health in the US has a conference on the “health" implications of obesity. We've now got the BMI. It's been anointed in the least dramatic way, as the least worst measure of fatness. And the NIH goes, “Great. We actually have to have a conversation about this at a population level.” They hold this conference that's designed to set medical categories for fatness. This is where we actually get categories that are being refined around who is “overweight,” who is “severe overweight,” who is “obese,” and who is “severe obese.” 

Mike: Right now, we don't have cutoffs. We don't have the 20 to 25 thing yet. 

Aubrey: Not yet. Basically, what we're about to talk about is a solid 30 years of those categories being redefined and renegotiated every 5 or 10 years by the US government. The way that we talk about “being overweight” or obese now, is we assume that that is tied to some level of the onset of health complications, or the increased risk of contracting certain diseases or whatever. The way that the NIH to find them was by a percentile of the population. 

Mike: Oh, wow. So, it's just like you're fatter than 90% of Americans, but there's no connection with you're 18% more likely to have cardiovascular disease, or none of that stuff is included yet? 

Aubrey: None of that stuff is included. This NIH definition from the 70s says that overweight people are anyone in the 85th percentile or above in terms of their weight in the late 70s. So, that's a BMI of 27.8 for men and 27.3 for women.

Mike: Wait, reverse BMI look up. Here's the BMI calculator. All right. Let's say 5’10”. Let's pretend I'm as tall as I am on my Tinder profile.

Aubrey: [laughs] 

Mike: And was it 27.5?

Aubrey: For men, it's 27.8.

Mike: 27.8. Okay, so if I'm a 5’10” dude, if I weigh more than 194 pounds, I'm, I guess, overweight? What's the category? 

Aubrey: Yeah, that's overweight. That's the start of being too fat. Severe overweight is the 95th percentile. It's the BMI of the 95th percentile. And then, they have a separate scale of measures for obesity and severe obesity. Both of those are tested by skinfold thickness instead of BMI. 

Mike: Okay, so once you get to a certain size, then they switch to skinfold? 

Aubrey: Not even once you get-- someone could be overweight, but not obese, or obese but not overweight, because they're using totally different measures.

Mike: Oh, weird. 

Aubrey: Like calipers, it's so fucking weird, dude. I think it's also worth noting that the cutoff for overweight in the 70s is 27.8 for men. The cutoff for overweight today is 25 for people of all genders. 

Mike: Here we go. 25, I'm a 5’10” dude. So, I used to be able to weigh 194 pounds before I'm overweight. Now, I can only weigh 174 pounds before I'm overweight.

Aubrey: Right. So, it's a 20-pound difference, just by the definitions that we use. These are really significant changes. We're in this moment where “ideal weights” are fully being invented. And there are people in a room going, “I think this is too fat.” “No, I think this is too fat.” Again, they're being defined not relative to health risks, but relative to other people. 

Mike: So, it's basically the biggest Americans must be at higher health risk. There's no diversity within that group. 

Aubrey: That's right. It is the largest Americans must be at the greatest health risk. They are because I don't like that they're so fat. What happens is that in 1985, the National Institutes of Health revised their definitions of obesity to also be tied to the BMI. So, they pull out the skin calipers thing, and they're like, “Okay, it's all BMI now.” 

Mike: At least it's consistently trash.

Aubrey: [laughs] Yeah, that’s right.

Mike: Rather than inconsistent. 

Aubrey: And that's when we really get BMI becomes the measure.

Mike: Because by 1990, we're fully in the obesity panic mode. That's when we've already had this wave of articles coming out about the future of our children and our national defense, and all this. The population is pretty well briefed by the early 90s. 

Aubrey: Yes, but we're not yet in obesity epidemic mode. 

Mike: Oh, is that later? 

Aubrey: That happens in 1995, and this is the thing I am constitutionally incapable of shutting up about at this point. In 1995, the World Health Organization decides that the BMI is going to be their new global standard for measuring overweight and obesity. 

Mike: That's bad.

Aubrey: As part of that decision, they do a couple of things that are very, very, very controversial amongst researchers and medical care providers. One, they decide to start using the BMI in children. 

Mike: Oh, what? 

Aubrey: Yeah. Prior to this, the BMI has been a measure for adults. There is quite a bit of back and forth at this time amongst pediatricians and pediatric researchers going, “It really does not make sense to try and tie weight to height for children,” because essentially, what happens in children's growth process is they grow out and then they grow up and they grow out, and then they grow up. Childhood and adolescence are a wild time to try and standardize bodies. 

Mike: We also don't have data on kids with a BMI of 26.4 at age 10 are 2.1 times more likely to have cardiovascular disease at age 50. It's so fucking noisy to even try to get that kind of data, because when we're talking about things like lifestyle diseases, like diabetes and cardiovascular disease, that stuff takes decades to happen. People's weights fluctuate wildly throughout the course of their life. So, a kid who's like fat at seven, you would need some pretty robust data to show that puts him at a higher risk of being unhealthy later. You really have to prove that.

Aubrey: Mike, I'm about to blow your mind. They did not have any of that data.

Mike: They did not have the data.

[laughter] 

Mike: Wow.

Aubrey: Basically, what they decide to do, they track growth studies from Brazil, from Great Britain, from Hong Kong, from the Netherlands, Singapore, and the US. They decide that what they're going to do is just extend the curve of the BMI for adults.

Mike: Just draw the line? Like just keep drawing the line downwards?

Aubrey: Yes. 

Mike: [laughs] 

Aubrey: That's all they're doing. And they're like, “This is for kids now.” 

Mike: Oh. I always love whenever I hear the phrase like, “If current trends continue--”

Aubrey: Yeah. [laughs] 

Mike: It's always like, “If current trends continue, like, 60% of the population will be obese in 2024,” or whatever. It's like, “Okay, but if current trends continue, 112% of the population will be obese by 2030.” Yes, if we're drawing trend lines, then they're going to exceed 100% at some point, so we can't draw the trend lines in straight lines, because that's not how trends work. 

Aubrey: That's right. The other thing that they do is that they get recommendations from WHO staff, saying, “Actually, our evidence shows that people can be healthy at higher weights. So, you should probably actually raise the floor for who's considered overweight and who's considered obese.” 

Mike: So, people are already sounding the alarm about this? 

Aubrey: They're already saying, “I don't think this measure is right. Actually, if we're going to adopt this as an international standard, we should probably say that overweight starts at a BMI of 30 or 28,” or something, quite a bit higher than it is now. In both cases, they do the opposite of what is recommended to them by healthcare practitioners. A bunch more people are now going to be considered medically overweight and medically obese. 

So, in 1995, the WHO changes their definitions of who is and who is not “overweight” or “obese.” In 1998, the US follow suit and comes into alignment with those international measures. That's how it's reported. It's like, “Uh, America was out of step with international guidelines. Now, we're in step with international guidelines, and, well, we got a lot of fat people.” CNN at the time has one of my favorite leads ever, which is, “Millions of Americans became fat Wednesday, even if they didn't gain a pound.”

Mike: Nice. [laughs] 

Aubrey: That goes on to say, “As the federal government adopted a controversial method for determining who is considered overweight.” 

Mike: So, like, “How was your week?” “I became fat. How was yours?” 

Aubrey: [laughs] Yeah, right. What happens is because we've now changed the standards, because it looks like there is an epidemic happening now that wasn't there before, it opens the floodgates for all of this research to be like, "Why is it terrible to be fat?" We were talking earlier about the research question of a bunch of these white dudes in the 1800s was like, “I know I'm superior to black people, but why?” And essentially, the research that we get here is, “We know it's terrible and unhealthy to be fat, but why?” Not like, "How do health measures play out for fat people?" There's no neutrality in these questions. They are just like, “How do we prove what we all already know, which is the fat people are hideous and they're going to die?” Like, “Oh, no.” 

Mike: What's frustrating about this is that there is very consistent data that at a population level, people with higher BMIs have worse health outcomes, so that's a real correlation. But there are things that correlate much better with health outcomes that we haven't put as much focus on. 

Aubrey: That's right. 

Mike: The correlation between, "Does this person get 30 minutes of exercise five days a week?" is a better predictor of bad health regardless of somebody's weight. So, it's frustrating that we had this panic over what people look like and how we can extrapolate that as a proxy indicator, when we could have been framing all these diet-related disease issues in a much more accurate way. 

Aubrey: The thing that I got stuck on, this is a perfect segue, why the fuck was this the thing? 

Mike: Yes.

Aubrey: I get that we're biased against fat people. I get the people have been grossed out by fat people or whatever, for a long time. But why did this in particular become not just a national, but an international health policy priority? I found an answer that makes me feel I need to wear a fucking tinfoil hat. 

Mike: Ooh, smoking gun, I want it. I want it so bad. 

Aubrey: I have the bulletin board full of news clippings with red string and pins and the whole thing. 

Mike: Wait. Is it going to be like Hillary Clinton trafficked a bunch of children? I'm nervous now, Aubrey. 

Aubrey: It all starts at cosmic ping pong. No. It doesn’t. [laughs] 

Mike: Where are we going now? 

Aubrey: No, we're not getting into Pizzagate territory. Thank Christ. 

Mike: Okay, thank God.

Aubrey: No, we're getting into something that is the answer is hiding in plain sight, and it also makes me feel like I am losing my grip on reality because it feels so conspiratorial. I'm going to send you this quote. This is what the British Medical Journal has to say about the International Obesity Task Force, which is the body in the WHO that has set these international standards. 

Mike: This quote that you just sent me, it just says, “Killary stole the election from Donald Trump.” Aubrey? 

Aubrey: [laughs] Lock her up! Lock her up! No. [laughs] 

Mike: Where are we going with this? Okay. “The most recent annual report of the newly merged group highlights close ties with WHO, but also shows that two drug companies, Roche and Abbott, are primary sponsors, supplying around two thirds of its total funding. Roche makes the anti-obesity drug orlistat. And Abbott makes sibutramine hydrochloride, known as Reductil.” These sound fake. “A senior member of the merged group who has seen funding documents but did not want to be identified, told the BMJ that over recent years sponsorship from drug companies is likely to have amounted to millions.” I see where you're going with this. 

Aubrey: Do you see where I'm going with this? 

Mike: It was Pfizer all along. It was these drug companies that want to sell us anti-obesity drugs. 

Aubrey: What this quote leaves out is that Reductil, which was sold in the US as Meridia, was in the approval process. Both of these drug companies have weight loss drugs that are in the approval process in the mid to late 90s. But first, they need to establish that weight loss is a going concern for medicine, and that a fuck ton of people need medical intervention to lose weight. What they are doing is they are establishing this as a medical concern at a new level and they are lowering these thresholds for what it means to be overweight and obese, so you can weigh the same amount and previously be at a “normal weight” and now be overweight or obese. And that is so that Roche and Abbott have customers to buy Meridia and Alli was Orlistat in the US.

Mike: Is that because they were BMI cut offs for doctors being able to prescribe these?

Aubrey: Being able to prescribe them and for insurance to cover them.

Mike: Right, yeah. So, it's like only over BMI 27.5, can you get this reimbursed? 

Aubrey: Right. Only the overweight and obese categories qualify for these medical interventions. If you can lower the threshold of who's considered-- if you can make more people “medically overweight” or “medically obese,” then you have a fuck ton more customers not only on an individual level, but you've got state contracts to handle the obesity epidemic. You've got large-scale sweetheart deals with insurance companies who will pay you untold amounts for untold numbers of people who now believe that they are overweight or obese, because their doctors are telling them that, so why would they not believe it? 

Mike: This is a little tinfoil hat, Aubrey. [laughs] 

Aubrey: It is a little fucking tinfoil hat. I kept looking for alternative narratives of how this happened. I was like, “I wonder what Roche and Abbott have to say about how this happened,” what different sort of entities involved in this have to say. There is no alternate narrative. This is the story of how this happened. 

Mike: There's also just the fundamental fact that any other solution to the “obesity epidemic,” bike lanes to school, or subsidies for healthy food, or higher food stamps, or all of these sorts of real solutions to diet related disease require political tradeoffs, and they cost money. There's no free lunch, the way that there is with fucking throwing pharmaceuticals at something. Whether or not this is a deliberate conspiracy by the drug companies and the government officials, or whatever, it's just a lot fucking easier. 

Aubrey: That's right. I also think, look, it's possible that the WHO is like, “We've got to get to this overweight and obesity thing at some point. We don't know how we're going to fund it.” And the drug companies swoop in and go, “What if we funded it?” There are a bunch of different ways that this could happen, but the fucking fact of the matter is, most of the budget of this international task force that's focused on defining who is and who is not overweight and obese, is funded by drug companies that absolutely have a stake in this outcome. 

Mike: It doesn't look good. 

Aubrey: That’s exactly right. It doesn't look good. Whether or not you believe that that is, they're wringing their hands and they're conspiratorially hatching a plan in smoke-filled rooms or whatever. Or, whether you think the WHO wanted and needed to do a thing, and drug companies altruistically agreed to fund it.

Mike: Which, like, no.

Aubrey: No, which probably not. Let's get back to just documented facts that we can for sure prove, regardless of intent. 1995, the WHO changes their definitions of overweight and obese. 1998, the National Institutes of Health in the US falls in line. Those changes are funded by Abbott and Roche. In 1998 and 1999, both of those companies have weight loss drugs approved by the FDA. It's the next two fucking years. What we know from our Fen-Phen episode is, this is after a decade's long drought of approving weight loss drugs. So, it is absolutely in their financial best interest to establish that there are more customers who need their product. 

Mike: Right. There's also a way that I think journalistic bias operates. If I'm writing an article about a school shooting, I can find experts that will say, “It's mental health. America doesn't have mental health treatment.” I can find experts that say, “It's guns. We have too many guns.” The bias in that article isn't necessarily in what the experts say, or even in what I write in the actual text of the article. The bias comes in, which experts am I consulting? That's a very invisible form of bias, because there's an infinite number of experts who I could consult on something as broad as that issue. I think as a guy who worked in international development for 11 years, and I worked on corporate human rights violations, that was the bulk of my human rights career, I have seen the ways that corporations warp the human rights issues that get talked about, and it is a lot of, which expert is going to be on the panel? Who is going to be appointed to this thing? I can absolutely see that happening here. 

Aubrey: Another way that bias in the populace is promulgated through media, even without intent, is that when we see reporting about the “obesity epidemic,” this entire history is nowhere. There is no discussion of, “Actually, we spent like a really long time defining and redefining and moving the goalposts.” There's no discussion of like, "You could have been at a “healthy weight” in the 70s stayed the same size and now be overweight." That's not an indictment of reporters doing that reporting, necessarily, but you can see how, when you make that history invisible to people, it really seems there is a very real threat out there. You know what it feels like to me is, we've got all these movies about shark attacks, and then you talk to shark experts, and they're like, “They pretty much never happen, but everyone's freaked out about them all the time.” We're being trained to see this as a function of the natural world. Not something that is a function of humans' interpretations of other humans. 

Mike: Right. This completely arbitrary scale that was essentially arbitrary for more than 100 years, and then we kind of backfilled the science, because we had already agreed on this one number as the thing that had to be the center of our understanding of health. 

Aubrey: That's right. Even when we're talking about these definition changes in the late 90s, which is so fucking recent, there is also continuing research that's coming out in the last 10 or 15 years that are adding even more complexity and nuance to our understanding about the relationship between weight and health. In 2015, researchers at Harvard and the University of Sheffield release a study where they say they found six different types of obesity, each of which have their own etiology. Just a couple years later, researchers at Massachusetts General Hospital say that they have observed 59 different types of obesity. 

We're trying to cram all of these different potential threads, rather than looking closer at, like, “Wait a minute. What's actually going on here?” Instead, we go, “Oh, my God, it's even worse than we thought. Fat people are terrible.” 

Mike: Also, from my years ago research into BMI stuff, there also is very different data based on race. The correlation between disease and BMI starts to show up at lower BMIs for Asian people, although there's huge diversity within Asia, obviously. But then, for black people, black people can be larger before those correlations start to show up. Again, it's all like there's other things that are more correlated and there's no way to talk about this without sounding like a eugenicist and shitty. But humans are diverse on every dimension, including the size that they're kind of best suited to be. It's not an academic issue that this was only done on white people. It's like an actual epidemiological issue. We're getting shitty data by applying this to everybody. 

Aubrey: And it's also been designed pretty much exclusively at this point still for cis men. 

Mike: Yeah, that's weird. It's also so dumb, because women are supposed to have far more body fat than men. 

Aubrey: That's right. There's no real research on the impacts of the BMI on trans people, but the BMI is used as a reason to deny trans people surgical care. That also plays out-- now that we're talking about a “global obesity epidemic,” there are all of these fucking rankings that come out, that are like, "What are the fattest countries in the world?" Would you like to guess at some of the top 10 fattest countries in the world? 

Mike: Oh, isn't it always Tuvalu and these other Pacific Island nations that are like have been large for most of human history? 

Aubrey: Yeah. The top 10 is, the Cook Islands, the Marshall Islands, Palau, Tuvalu, Tonga, Samoa. In addition to all of the garbage science stuff, we also now have this handwringing about the health of populations that have always been in this size range. Not only that, but in the United States, the way that we categorize race and ethnicity lumps together Asian and Pacific Islander communities.

Mike: And East Asian and South Asian communities too.

Aubrey: And East Asian and South Asian. Asia, all of it. 

Mike: It's like 40% of humanity in one category. 

Aubrey: Yeah, totally. If you are looking at race-based differences for how the BMI plays out, the idea that Japanese people and Samoan people would be in the same category, as interpreted, it's just wackadoo. It makes zero sense. And India and China, which are not in the top 10 of most “obese nations,” have some of the highest levels of type 2 diabetes diagnoses. Because we're looking for fat people and the problem of fat people, we're also missing opportunities to intervene on other public health issues.

This is also where we get into some of the pitfalls of conversations that critique the BMI. I think one of the ones that we talked about is trying to find villains in history. I'm calling myself out with this one. It's like you can say The Rock is obese by the BMI, that's how you know it's so wrong. The implication there is, if it really detected fat people, then it would be okay. But the problem with the BMI is that people who are not fat get lumped in and that's not right. But if it's just fat people, it's fine to have a war on obesity. It's fine to have all of this shitty public policy.

Mike: It's very hard to say both, the BMI is trash and it's bad that there aren't separate BMIs for Samoans and Japanese people. That's basically kind of the argument that we're making, but not really. 

Aubrey: That's right. I think the underlying question here is, why is it critical to the State to define an ideal weight? 

Mike: The central issue with me is that the BMI and fatness generally, has always been presented to us as a proxy indicator. Fatness is bad, because fatness is an indicator that you are more likely to get heart disease, that you have bad cholesterol, that you have all of these underlying health conditions that we can't see. And because we can't see cardiovascular risk, we use fatness because it's all we have. But then, what's fucking insane about using the BMI within the medical system is you can take people's cholesterol, you can actually ask them, “What are your lifestyle factors? What is your genetic background that puts you at higher risk for heart disease?” We're still using a proxy indicator for underlying data when the underlying data is there. If we don't want people to be fat, because they might have a bad resting heart rate, we can take their fucking resting heart rate. They're in a doctor's office.

Aubrey: And there are interventions that we know work for those specific things. But instead, we use this proxy as the measure for the health risks. And then, we try to control the proxy as a way to control the health risks, rather than just fucking controlling the health risks.

Mike: Just controlling the health risks. Why do we need this intermediate thing? And why have we put all of our effort into this intermediate thing if it's supposed to be the tip of this health iceberg? Let's just look at the iceberg.

Aubrey: That's exactly right. This is one of those places where I'm like, if you want to talk about health, if that's the thing that you want to talk about, and you really genuinely care about population level health markers and individual care of individual patients, then the BMI is leading us away from that. That also traces back to the entire fucking history of the entire fucking thing, which was like, a dude who thought he was doing a population level analysis, and then a series of people who grabbed on to it, largely for profit motives. First insurance companies and then drug companies. It does feel really challenging to figure out how to have this conversation, and I will say it feels challenging to me as a fat person, because I think it's easy for me talking about this to read as a very self-serving set of conclusions. 

Mike: Yeah, I was just going to accuse you of glorifying obesity. 

Aubrey: Thank you. 

Mike: [chuckles] 

Aubrey: I'm trying my best. 

Mike: That's how all of our episodes end. 

Aubrey: You saw my eyeliner today. If that's not glorifying obesity, I don't know what is.

[laughter] 

Mike: Glory be.

Aubrey: [laughs] I didn't really sleep particularly well last night. I was all churned up about recording this episode. 

Mike: Oh, no way. 

Aubrey: Which usually happens like a little bit, but not to this level. I think a lot of that has to do with being a fat person saying into a microphone, "Here's what I researched and found" about something that is seen as self-serving. It made me think about when we had our marriage equality court case in Oregon, the circuit court judge who was assigned was a gay man, and there was a big outburst about like he can't be impartial. 

Mike: For fuck's sake. Yeah.

Aubrey: I am genuinely nervous about how this conversation plays out from here. 

Mike: But what's so fascinating is that this accusation against you implies that thin people don't have any dog in this fight, and that's not true. 

Aubrey: Yeah, that's right. 

Mike: Whether you are fat or thin, your body size affects the way that you see the world and the way that you interpret political and social issues. Thin people also have a reason to think that fatness is bad and to think that you are virtuous for being thin, as opposed to you were born with pretty good genetics or whatever. I hate to be the person who's like, “Well, what about the people with more power?” But the BMI is not working for skinny people either, because you have people like Bob Harper, the demonic personal trainer who hosts The Biggest Loser, who does more exercise than anyone else on planet Earth, who has a heart attack in his 40s.

Aubrey: And then, goes back to hosts The Biggest Loser and it's like, “And that's why all of you need to lose weight.”

Mike: Exactly. There are people who have risks of lifestyle disease and genetic diseases, and we're like, “Well, you're thin, so I don't need to run those tests for you.” It's much worse for fat people, but it's not working for anybody. 

Aubrey: And it's much worse for fat people. It is arguably the worst of all for fat people who are chronically ill. 

Mike: Yeah, my God.

Aubrey: Because then, the response from thin people writ large from fat people who don't have chronic illnesses and from institutions and medical systems is, “Well, you brought this on yourself. You knew the risks, you could have controlled your weight, and you didn't.” 

Mike: This is my tinfoil hat turn in the episode. 

Aubrey: Oh, my God, tell me. Join me. 

Mike: I actually think that we are vastly underestimating the effect of medical bias as a driver of the “health effects" of obesity. This is anecdotal, it's really hard to get data, eventually, we will understand this phenomenon more. But for our show, after I wrote my article about obesity in 2018, our inboxes are jam packed with people who are like, “I had a fucking tumor for years that nobody diagnosed because they kept telling me to lose weight.” Very severe health effects that nobody looks into because it's like, “Oh, you're fat, so I'm not going to run these tests on you. I'm not going to give you an MRI, I'm not going to listen to you, I'm not going to believe you until you lose enough weight that you appear as a person to me.” 

Like I said, there is a correlation between higher BMI and worse health. Some percentage of that is also the fact that life-threatening illnesses in fat people do not get fucking diagnosed. 

Aubrey: And on top of that, 100%, the number of horror stories from individual fat people out in the world--

Mike: People do not understand how common this is.

Aubrey: People really, really, really don't understand. It is one of the great fears of my life, that I will die of a totally treatable or preventable thing, because my doctor can't conceive of me having any other health problem than just being a fat person. That is a fear that follows me every time I go into the doctor's office, it's terrible. And two other things that we know for sure, you're right, that this is hard to get good data on, the specific misdiagnosis stuff. But I will say we do know for fucking sure that there is a lot of data that says that fat people generally and fat women, in particular, postpone care, because they know that they are going to be overtly directly judged by their healthcare providers, and they know that they will get substandard care because of that judgment. 

I've written about this, that I went for years without seeing a doctor because I just knew that it was just going to be another fucking weight loss lecture because I went in for an ear infection at one point and my aftercare instructions were to lose weight.

Other thing that we know for fucking sure is that there's quite a bit of data on when and where fat people report experiencing weight stigma. Number one is friends, family and intimate partners, which is real shitty. So, everybody, all of us do a little reflecting. That's real bad. Number two is healthcare providers. It's really tricky to figure out how to talk about medical bias in a way that doesn't seem like anti-doctor too or anti-healthcare provider, that is like, “No, I really fucking need what you're offering.” Right now, I can't actually get it from you. 

Mike: I would say when you look at these consistent correlations between fat people and lower life expectancy, it strains credulity that a population that systematically does not seek medical care, that that would have nothing to do with their shorter life expectancy. That is absurd to say that like, “Oh, yeah, by the way, fat people are delaying care for years. We shouldn't be factoring that into our understanding of the relationship between weight and health.” It is nuts to think that it would.

Aubrey: Yeah. The other thing that we do have quite a bit of data on, is there is a lot of data and it is straight up self-reported data from many different kinds of healthcare providers that show things like a majority of nurses and nursing students think that fat people who are admitted to the hospital should forcibly be put on very low-calorie diets. 

Mike: Yeah, it's really bad. Every study that looks into this finds like, “Oh, this other group is also biased against fat people.” 

Aubrey: Right. It's every time someone just asks, it's not even, like, “Let's measure their patient interactions.” It's just like you just go up to a doctor or a nurse or a physician assistant or whoever, and you go, “Hey, what do you think about fat people?” And they're like, “Oh, that they're lazy, and that they're not going to following instructions and that they're probably going to die, and that I shouldn't have to treat them.” There is also some data that shows that any intervention starts to change that. 

There is one study that shows that a 15-minute video clip shown to medical students decreases their levels of bias against fat individuals. It is truly all we have to do here is anything, but right now, we're using this system, which is the BMI, it treats it as if there's a straight line from being fat, to being in ill health, to being a patient that's not worth caring for. And because we also have this myth that we're really committed to, that your personal weight is 100% in your control 100% of the time, then we can also infer intent from fat people. But you're not just seeing someone whose body looks different than you, you're looking at someone who's deciding not to be thin all the time. So, you can decide to do whatever you want, including deny them healthcare, whatever the things are.

It's a really tricky, challenging conversation to get into without feeling like you're assailing someone's intent. It's really not about those things. It really is just fat people are fucking desperate for decent health care, and we're not getting We just don't know how to get anybody's attention, to just be like, “Can you please just treat me like you would treat a thin patient?” 

Mike: It is a weird move for doctors to be like, “I had to be mean to this patient. She's unhealthy.” I think it's actually you should probably listen closer to those patients. 

Aubrey: Yes. Arguably, the patients who you are perceiving as being unhealthy are the people who need your help the fucking most. So, can you not be a dick to them? 

Mike: Maybe let's spend more time with those patients if they're fat, and they're telling you about their migraine.

Aubrey: Yeah. Have I ever told you about HONDA’s? 

Mike: No.

Aubrey: HONDA is the acronym that is disproportionately used to describe fat patients. It stands for hypertensive, obese, non-compliant diabetic, alcoholic.

Mike: Holy shit.

Aubrey: Sometimes the A stands for asshole. Some healthcare providers somewhere think that that's actually an okay way to talk about fat patients, and think that they can then provide care in an unbiased way to that person when they're starting from a place of like, “I've already decided that you have high blood pressure, that you have diabetes, and that you're noncompliant. I’ve already decided you're not going to listen to me.” 

Mike: I love the noncompliant part, because it's like, “He can't even lose weight, which fails for 98% of people. He can't even do this thing that only 1 out of 50 people can do.” 

Aubrey: He's failing the thing that everyone fails at. [fart noise] Ridiculous. 

Mike: There's the moral arguments, which I feel don't really work when we're talking about like issues of bias. You're not going to get people in their hearts, but the last numbers that I've seen are that one-third of “obese people” have normal health markers, and around 25% of average weight people don't have normal health markers. If you are relying on the BMI, you're basically calling a bunch of fat people unhealthy who aren't, and you're basically calling a bunch of thin people healthy when they aren't. Even if you want to keep hating fat people, if your goal is to have a healthier country, you would not be using the BMI. 

Aubrey: Totally. There's a bunch of really good and interesting health data that I found. We'll talk about this next time, the idea of the “obesity paradox.” Is this a phrase that you've heard before? 

Mike: Isn't this like, “Some fat people are healthy?” [laughs] 

Aubrey: It is. And not only that, but fat seems to protect some people from some health condition. So, fat people are more likely to have heart attacks, but less likely to die of them. It all gets labeled the “obesity paradox,” which is just, “These fat people seem healthy, but that's not possible.”

[laughter] 

Aubrey: We're like, “Oh, fuck.” 

Mike: That’s like some 18th century medicine shit, where they're like, “This black person is smart.” The race paradox. It's like, “No, it's just your whole understanding of this issue is fucking wrong.” 

Aubrey: “This woman seems to be able to do things for herself. What?” It's like you are showing your whole ass. I think the other thing that these conversations all leave out, is that the jury is still fucking out on a lot of this stuff. But we are treating it like it is hard and fast medical knowledge. But if you talk to researchers who are working on this, like evolutionary biologists who are researching this stuff, they're like, “Actually, we just found out that your body adjusts to burn the same number of calories regardless of the amount of activity that you're doing. We don't really know why that happens. Anyway, bye.” [laughs] If you actually talk to the sources of the research that we all seem really secure that we think we know, they will tell you that we are wrong. That's the BMI. I feel I am losing my grip on reality. 

Mike: Our next episode is going to be about Benghazi, isn't it? 

Aubrey: [laughs] 

Mike: Aubrey is going down the rabbit hole and lost it. This is it. 

Aubrey: Totally. Look, I'm just saying you make some good points. Our next episode actually will be about how this these shifts in the BMI pave the way for declaring an obesity epidemic and policy history behind the obesity epidemic, which also is termed “war on obesity.” So, we'll talk about that next time because, boy, oh, boy, there's a lot going there. 

Mike: There's a lot of meetings in Switzerland that we need to talk about. Can I end this with a little parable? 

Aubrey: Yes, please do. I would love it. 

Mike: One of the things that stuck out to me from all this race and IQ stuff that I've been reading, the most famous IQ test is called the Stanford-Binet test. Alfred Binet came up with these ways of measuring IQ through multiple choice questions. He deliberately came up with this measure as a way to get more attention on kids who needed it the most. His goal with coming up with this IQ test was to be like, “There's probably kids that are falling behind in school, and we don't know about them.” 

Aubrey: Oh, wow. 

Mike: And, of course, 10 minutes after he comes up with the scale, people like, “Let's sterilize the children.” It, of course, becomes this runaway train the minute there's a measurement out there, because there's always this drive to quantify things. I think so much of it is the fact that our country is dominated by men, and there's something that feels valid about a number that doesn't feel valid about any kind of qualitative measure. I really think something similar happened with the BMI where it's like this number never really meant very much. And there was always so much diversity, two people who both have a BMI of like 26, one of them could be super buff, and one of them might have had an eating disorder before and telling her to lose weight is not a fucking great idea. These numbers take on this implied scientific rigor that makes us take them far more seriously, and especially makes institutions adopt them much more than they should and takes away all of the nuance. 

Aubrey: And because we all have pretty serious implicit biases on a bunch of different measures, we are also pretty incapable of internalizing those measures without using them to justify the people that we already think are superior being superior and the people we already think are inferior being inferior. We don't do a really good job of taking in research results without turning them into individual mandates. There was that whole wave of stuff about visceral fat is the fat that's really bad for you, belly fat is worse for your health, and that turned pretty quickly as a fat person into people being like, “You have a lot of belly fat, that means you're going to die. You need to lose weight.” I'm like, "I can't control where fat accumulates on my body." This is scientifically useful, I'm sure. And also, on an individual level, there's not an instruction that follows from there, that’s like, “Oh, you guys are right. I guess I should have a different body shape.” I don't know how to do that. 

Mike: Yeah. “You're a pear and I need you to be an apple.” It's not useful advice for people.

Aubrey: Again, talking about the nuance of this story in this history, the failings of the BMI are mostly failings of humans, which makes it really fucking challenging to talk about this stuff when it gets presented as like, it's just capital T, capital S, the science. 

Mike: Yeah. Although, Aubrey, people named Mike really are better than all--[crosstalk] 

Aubrey: [laughs] 

Mike: -that’s my firm belief. It's science. It's objective. It's objective science.

Aubrey: You're like, “I created a system wherein short, white men are at the top of the pyramid." [laughs] 

Mike: You know what? 5’6” gay Mikes, turns out looking at a piece of paper. Sorry, it says here, we're the best. 

Aubrey: Science.

Mike: Yeah.

[laughter] 

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