Over the last 30 years, fatness has been defined as a risk factor for disease, then a disease in itself, then a global epidemic. What caused this rapid shift? Who’s gonna join our group of B-roll vigilantes? And did we just hear Morgan Freeman?
Mike: Welcome to Maintenance Phase, the podcast that would never film you from across the street showing only your body and not your head.
Aubrey: There's actually research on that specific thing.
Mike: I know.
Aubrey: And we're totally going to fucking talk about it. It's like you already know, Mike. It's like you already know.
Mike: This is the thing. The only places in American life that you see that many headless torsos are local news segments about obesity and Grindr.
Mike: As a gay man who researches this issue, I am very familiar with this format.
Aubrey: Yeah. Go down the whole rabbit hole. The rabbit hole, also a section of scruff.
Aubrey: I'm Aubrey Gordon.
Mike: I am Michael Hobbes.
Aubrey: If you would like to support the show, you can do that through Patreon patreon.com/maintenancephase. You can also buy t-shirts, mugs, masks, they're coming back, at TeePublic on our TeePublic Store. Both of those are linked for you in the show notes and at maintenancephase.com.
Today, we're going to talk about The Obesity Epidemic.
Mike: Yes. Our morbidly awesome obesity trilogy.
Aubrey: How do you come to this topic? What would you characterize your baseline analysis?
Mike: This is a part of the story that I'm really interested in, because we both grew up at this time when there were just constant cover stories in Time, Newsweek, New York Times, Atlantic, you name it, they had a cover story about “The Obesity Epidemic.” There's the kids in obesity, there's the military in obesity. It took on a different flavor every year, but just clockwork. But what's your relationship? Do you remember those stories? You remember hearing that phrase when you were a kid?
Aubrey: Yes. In charting out this history, I was like, “Oh, this was when I was in high school in college. What a great fun time to have people hyperfocused on how terrible fat people are." You're a fat high schooler, don't feel bad enough? Get ready.
Mike: Yeah, here comes The Atlantic.
Mike: Here are some statistics to drop on you. [chuckles]
Aubrey: So, that's my relationship to it is this wave of media stories that was paired with a wave of people in my life who had spoken about my size before, but never in terms of health. Who maybe had said that doesn't look good on you at that size or maybe had said, think about how cute you'd be, think about the clothes you could wear if you just lost some weight. What happened during this time, is that all shifted to, “I just want you to be around and I want you to stay alive and you're going to die.”
Mike: That's interesting that immediately it became something that people used to attack you personally, because all of these stories, I feel went out of their way to be like, “Well, we can't necessarily use it for individuals.” They have the standard caveats. But, of course, all of that disappears once people kind of absorb the information and regurgitate it back out. Of course, people are going to apply it to every fat person they know.
Aubrey: Should we dive on in?
Mike: Let's do it. Take me on a journey.
Aubrey: Excellent. I wanted to start with context and what we know about rates of fatness, what things are changing and how, and what researchers actually tell us about the nature of fatness and fat people. We're not going to go super deep into the fat and health correlation stuff, not because that's not important, but because we're going to do a full episode on just that.
Aubrey: We have this collective sense that obesity and overweight rates are on a rocket ship to the moon, and they're showing no signs of slowing, and the data shows us something significantly more moderate than that. Basically, obesity rates are increasing. And I will say, I'm going to use the terms overweight and obesity, not because I love them, but because they are the terms for the BMI categories, and all of this obesity rate stuff is decided based on the BMI. There's not another measure of overweight or obesity that folks are using here. It's just BMI categories.
Mike: We need to talk about your fat phobia, Aubrey.
Mike: [crosstalk] -update your language.
Aubrey: Here's what we know. One, we know that obesity rates are increasing. Some folks chart that back to the 70s. Some folks chart it back to the 40s. But either way, there's been this pretty slow and steady climb of the rates at which people are moving into the “obese" category of the BMI. The rates of overweight are not increasing. It appears that people who are already in the overweight BMI category are moving into the obese category, but not necessarily that a bunch of thin people are suddenly becoming fat. Nobody knows why either of those things are happening. Fat people could be fat because of leptin, because of insulin insensitivity, because of the built environment, because of genetics or epigenetics. This is what they call a multifactorial phenomenon.
Mike: I also think in the same way we've had a million articles about the obesity epidemic is out of control, we've also had a million articles of, like, "Does this random thing explained the obesity epidemic?" Gut bacteria has been a big thing the last couple of years. There was a wave of sleep, things that Americans aren't getting as much sleep, and that's why obesity-- those wacky explanations could be part of it, but it's never going to be one thing.
Aubrey: Totally. In addition to body size being influenced by all of these complex factors, so are the diseases and health conditions that we associate with fatness. Heart disease, stroke, cancer, diabetes, all have multiple sources, causes, triggers, contributing factors, all of that kind of stuff. And the relationship between fatness and these health conditions is also complex and not super well understood scientifically. In addition to that, just a couple more things as baseline things to get out. One, obesity is not a cause of death. There is not a death certificate that says this person died of being fat. It is correlated to things that are causes of death, but just that in “epidemic” that's fueled by this idea of obesity-related deaths, it bears repeating. That's not actually a thing that we can say for sure.
One of the things that I found in so much research, so much goddamn research for this episode, Mike. I'm tired of reading books.
Mike: [laughs] You love it.
Aubrey: I need TV for a couple of days, and then I will be back to furiously reading like a book a day and I'm like, "Everything is a lie."
Mike: You need a Netflix reality show stat.
Aubrey: Okay. The turn that we're going to explore today is that all the way up until the mid-90s and then in a major way, in late 90s, mostly people just saw fatness as a result of lifestyle choices. It wasn't framed as a medical problem until very recently, historically.
Aubrey: 1999 and 2000 really seems to be where we get this term, “the obesity epidemic” coming out in full force.
Mike: I always like finding new ways in which the 1990s were trash.
Aubrey: Oh my God, Mike.
Mike: That’s part of the project today.
Aubrey: We're going to go 1990s, we're going to go 2000s, and it's going to be a tour through your high school, college, and early 20s.
Mike: I hope we talk about Camryn Manheim.
Aubrey: Our story begins, Michael, it begins in 1997. There is this small but growing group of researchers, clinicians, public health people who really thought that we were getting the conversation about fatness and fat people all wrong. And that, frankly, it's just not getting enough attention. They just can't really get the time of day from the media in the way that they would like to be able to. And they really do see this as a catastrophic kind of thing in some cases. The biggest champion of that, the biggest believer is a pediatrician named William Dietz. In 1997, he becomes the Director of the Division for Nutrition and Physical Activity at the CDC. Here's a quote from a book called Fat Politics by Eric Oliver. Actually, I might send this to you. Are you up for reading the quote?
Mike: Let’s do it. It says, “Obesity, viewed by many as simply a consequence of lifestyle, was not seen as a disease transmitted across populations. Dietz, however, held a view that was becoming more prevalent within medicine, that obesity was a condition influenced by the environment and a condition that people passively experienced. Something that happened to them rather than simply the result of their own choices. In other words, obesity was a disease.”
Mike and Aubrey: Dun, dun, dun.
Aubrey: So, this guy, Dr. Dietz, takes this on as his pet project.
Mike: We're also already getting the Maintenance Phase dramatic irony sugar high, of someone who seems to be doing their best and someone who’s like, “Oh, it's a disease. And if we reclassify it as a disease, people will see it as this complicated phenomenon influenced by the environment, rather than a failure of personal ethics.” That's not what America learned about this phenomenon over the next 20 years.
Aubrey: Mike, my next bullet point in my notes just says, “They're playing our song, because they totally fucking are,” like, good scientists means well. It goes sideways. So, part of how this goes sideways is actually in how Dietz communicates this set of ideas, he comes up with these heat maps, those maps that are an outline of the US and each state is shaded into a different level.
Mike: It's like number of food poisonings or whatever, and then some states are dark purple, and some states are green or whatever.
Aubrey: Totally. That's the way that he decides to convey to his colleagues, the rising rates of fat people. It moves from white to pink to red, first in a few states, and then in more and more. He's doing this over time, and it really physically looks like the spread of a contagious disease.
Mike: Yeah. I've seen those charts. It looks like one of those scenes in Outbreak or something. They're like, "[unintelligible [00:10:33] spreading."
Aubrey: [laughs] It's just rough. But also, it's the first time that someone has put this in map or talking point or jazzy, concise terms. So, those maps catch on wildfire. They catch on like a disease. They're suddenly everywhere. Academics start using them, public health officials start using them, and within a few short years, that turns into folks publicly referring to obesity as an epidemic. That's all happening in 1997, in 1998. By 2000, medical institutions start adopting new frameworks around defining overweight and obesity as diseases unto themselves.
A few short years later, in 2008, The Obesity Society is an organization whose tagline is 'professionals collaborating to overcome obesity,' they pulled together a panel of experts to consider this question of whether or not obesity is a disease. This is a quote directly from them. They couldn't come up with a real answer to this question, “Because of a lack of a clear, specific, widely accepted and scientifically applicable definition of disease.”
Mike: Yeah. This sounds like the neverending debate between what's a dialect and what's a language but it's much more a distinction about power dynamics than it is about linguistics.
Aubrey: Yeah, totally. This is another one of those places where there is a group of people in a room messily making a messy decision.
Mike: Another element of this that's tricky is that I think people in science don't want to talk about outcomes, because the purpose of reclassifying something as a disease is to achieve a particular outcome. It's to get political attention on it. It's to get public attention on it. All of that is fine but oftentimes, scientists' refusal to acknowledge that they're political actors, leads them to make very politically bad decisions.
Aubrey: I think part of that is that it feels uncomfortable to go. "You know what? I actually have a dog in this race," you know what I mean? Okay. And that's ultimately where they land. They pick another a couple of guideposts. One is that they look to their peers in medical communities, and they see some growing support for considering these rates of fatness to be a disease. And then, they do your favorite thing, Michael Hobbes. They weigh the imagined benefits, the imagined harms.
Aubrey: And they decide that the imagined benefits outweigh the harms.
Mike: Always is.
Aubrey: [crosstalk] -would be more beneficial in each of these decision-making processes, the WHO, The Obesity Society, we'll get to the American Medical Association in a minute. There is no consulting with fat people.
Mike: Yeah. I mean, I don't know if they would have been any better on other minority statuses at the time but fatness is a minority status that is considered to be temporary. No one says, “Right now he's Asian American, but later, he might not be, so we don't need to consult them on this.” I feel people skip like, “Let's talk to fat advocacy groups about this step in these kinds of processes,” because they're like, “Well, they don't want to be fat anyway.”
Aubrey: Yeah. I already know how fat people feel about themselves. They hate it. They're disgusted by themselves, how could they feel any other way? And it's like, “Well.” The WHO changes their definition of obesity as a disease in 2000. In 2008, The Obesity Society changes their definition and recommends defining this as a disease. In 2013, the American Medical Association kicks in as well and goes, “Yeah, actually, it's a disease.”
Mike: Okay, so all the dominoes are clicking into place now.
Aubrey: There is a great New York Times piece, it's just called “AMA recognizes obesity as a disease,” that encapsulates so much of this. I'm going to send you two quotes, and I'm going to have you read both quotes.
Mike: Ooh, ooh. “The American Medical Association has officially recognized obesity as a disease, a move that could induce physicians to pay more attention to the condition and spur more insurers to pay for treatments. In making the decision, delegates of the association's annual meeting in Chicago overrode a recommendation against doing so, by a committee that has studied the matter.” Whoops.
Mike: So, they assigned a committee to study this, and the committee was like, "Don't do this," and then they did it.
Aubrey: They spent a year studying this. And they were like, “It's a bad idea.” And then, AMA was like, “No, it's not.” Part of the reason I wanted to lift this up is, A, I think, when we hear proclamations like this, it's easy to think like, “Oh, that represents consensus.” In this case, it does not represent consensus. It represents an institutional position, which differs from-- there's a difference of opinion happening here. Also, I wanted to lift it up, because, holy shit, this is the exact thing that happened at the World Health Organization when they redefined the levels of overweight and obesity and adopted the BMI as a thing, that there was all of this disagreement, and they were going against their own recommendations.
Mike: No one is ever going to build a statue to the people that are like, “It's a little more complicated.”
Mike: "We don't necessarily disagree, but we just want to slow down."
Aubrey: Is this your way of telling me that you and I are never going to be statues in a park?
Mike: 1,000% true.
Mike: Let's just all take a minute. That person does not get biographies written about them.
Aubrey: Yeah. I was going to send you quote number two, but I'll tell you this. Basically, in this new story, they then go on to talk about how the committee voted against calling obesity a disease, because it's based in the BMI, and the BMI is oversimplistic and deeply flawed. So, they straight up are just like, “This is a bad idea, because the BMI is a bad idea. And until we get some other kind of grounding in this issue, that's not rooted in this really terrible tool, then we're not in a place to make this proclamation."
Mike: That's actually interesting, because it's not even a woke objection, or whatever, like, "This is going to hurt people's feelings." It's like, this is just bad science. Even if you think that body fat induces all these problems, you still wouldn't be using the BMI for The Rock problem that we talked about last episode.
Aubrey: No question. And both because of The Rock, or Tom Cruise or take your pick. But also, because at this point in 2013, the science is even more thin than it is now on what the correlations actually are to these other health conditions and diseases.
Mike: Because there's already studies starting to come out that show that it's not perfectly correlated with negative health outcomes, this debate is already going on what are the health effects of obesity?
Aubrey: Yes. When you look back at a bunch of the data, it seems to show that those correlations really kick in, some folks say at a BMI of 35 and some folks say at a BMI of 40. We're talking about a very small portion of the population. I'm in that portion of the population, other fat people are in that portion of the population. But at this point, it's not an overwhelming majority of Americans, who are in the high health risk category. Even in that high health risk category, we don't totally know what's going on. It is interesting to me, I will say, that you mentioned it's not even a woke reason, because that's what the AMA gives as their reasoning for overruling the committee.
Aubrey: The AMA gives a few strains of reasoning. One, they say that it would help the public and elected officials take the “obesity epidemic” more seriously. I would argue it sure did that.
Mike: Good God.
Aubrey: Two, is that it could help increase insurance coverage for treatments. But again, none of those treatments make a majority of fat people thin in the long term. So, like, “Sure, man, cover treatments, I guess. But shouldn't those treatments also be shown to work for more than 5 to 10 pounds of weight loss?"
Mike: Also, just all of the ways the US' completely broken healthcare system, warps all these other elements of our lives, because our healthcare system is so unjust, that your insurance company can just like not cover you for stuff for no fucking reason, the entire medical industry has to be like, “Okay, how do we trick the insurers into paying for this?”
Aubrey: Well, and also what if instead of spending a fucking year as a study group being like, “Is this a disease or is this not a disease?”, what if instead of doing that they put that energy into addressing weight stigma or maybe just fixing the whole healthcare system and advocating for-- you know what I'm saying?
Aubrey: There are things that we know would and could help that are way less murky than this.
Mike: But this is the problem, is that requires them to act politically. This thing of like, "We're doctors, we're outside of the political system," is what prevents public like health issues from being solved. You can't deal with an issue like this without playing in politics. You can't really deal probably with any health issue without playing in politics. Politics is how you solve a lot of these issues.
Aubrey: Absolutely. Also, can I add another-- we're going to get a little echo of our BMI story here.
Mike: Do it.
Aubrey: One of the next things that they say in this new story from New York Times is, “Oh, by the way, while we're trying to get these treatments for obesity covered, there are two new weight loss drugs on the market.”
Mike: Of course.
Aubrey: "They're actually not selling as well as we might have thought." They just they straight up put that in this article. It's like, “We're going to get all this insurance covered. Also, these weight loss drugs have been underperforming." They don't say, hopefully, [crosstalk]” but it really feels like that's the missing sentence here.
Mike: God. Speaking of structural incentives, man, the doctors want to get out the pills.
Aubrey: Well, the manufacturers of those drugs want them to sell better. The third reason is they say, “We think it's going to help reduce stigma facing fat people.” This is the William Dietz’s approach, which is like, “If we can call this a disease, then people will understand that it's really complicated, that it requires lifelong management,” and people don't actually understand that. Again, this is a place where I'm like it would have been so helpful to talk to some fat people. And that doesn't appear to have happened.
Mike: It is interesting, because it sounds like they really were on some level doing this in good faith, thinking that the term 'disease' takes agency away from the individual. But once you start to associate a person with a disease, you're going to stigmatize the individual.
Aubrey: Yeah. I think this is borne out in the public response to this AMA decision. There's some folks who express some relief and agreement. Those are mostly people who are clinicians or obesity researchers. There is some nervousness from predominantly fat people that this is going to increase stigma. And then, there is a pretty broad base of public response that is disapproving of this decision and that it will downplay personal responsibility.
Mike: Oh, this is like anti-woke people who are like, “You're going too easy on the fat people.”
Aubrey: Critical race theory.
Mike: Those are the real heroes in all of these debates.
Aubrey: I don't want my kid in kindergarten to know that it might be okay to be nice to a fat person. Boom.
Mike: I always love whenever you have these debates, there's always someone pops out of a fucking trash can to be like, “We're already too nice to this stigmatized group.”
Mike: We're already pretty mean.
Aubrey: Even when you have a shared framework for conversations like these, we still fill in the blanks with our own biases. To my mind, when this news came out, I was like, “Oh, we're fucked.” I absolutely remember when the AMA thing came out, and I was like, “I hate it. This feels really bad, and it feels like people are going to be more of a dick to me,” and that's absolutely what happened. We're talking about eight years ago. So, think about the amount of the volume of news stories, the volume of research that's happened at that time, it's significant.
Mike: Camryn Manheim’s book had already come out.
Aubrey: [laughs] Wake Up, I'm Fat!
Mike: Yeah. Which I read in eighth grade.
Aubrey: Did you really?
Aubrey: Oh, my God.
Mike: This is like a huge precursor to me being gay, of course. I'm like, “I'm obsessed with a fat lady who's on TV.”
Aubrey: A fat lady who seems kind of gay.
Mike: [laughs] I know. I was also really into Rosie O'Donnell. And then I told my parents I was gay, and they're like, “We had no idea.” I'm like, “Guys.”
Aubrey: You just kept asking for Koosh slingshots to fire into an imaginary audience. You're like, “I'm a Rosie O'Donnell stan. Here we go.” There are some organizations, some anti-obesity organizations that feel this is again, shortchanging the conversation. The biggest one of those anti-obesity organizations is the American Obesity Association. They're founded in 1995. They describe their work as centering around treatment and prevention of obesity and reducing stigma. All three of those things. But then, they say, “We want to reduce stigma for ‘Americans suffering with the disease of obesity.’” [laughs] Which I'm like, [groans] “Do you want to reduce stigma?”
Mike: It's also not clear to me that you can reduce stigma about a group that you're trying to erase on some level. You should lose weight, but also people shouldn't be mean to you. That's a tough little tightrope to walk.
Aubrey: It feels a little bit like the solution to people bullying gay kids is for gay kids to act less gay and maybe just be straight. We're like, “Well, no.”
Mike: Straighten those wrists.
Mike: Butch it up.
Aubrey: The American Obesity Association claims credit for a lot of policy changes. They claim credit for influencing the Office of the Surgeon General on this issue. They are major drivers of this idea of obesity as a disease. So, we've got this director at the CDC, Dr. Dietz, and then we've got the American Obesity Association, both really tackling this hard, and going hard on, “This is a disease.” One of the biggest sources for this episode-- there are three books that I read that were all fantastic. One of them is a book called Fat Politics by a sociologist from the University of Chicago named Eric Oliver. He did a bunch of research into the American Obesity Association, and he found that the organization was nearly fully funded by weight loss companies.
Mike: No way.
Aubrey: So, they are funded by Weight Watchers. They're funded by Jenny Craig. They're funded by SlimFast. They're funded by weight loss surgeons. And, Mike, would you like to guess who the final funder is? Is it our old pals at Roche? Yes, it fucking is.
Mike: I was just going to say. You're slowly putting a tinfoil hat on me. I'm kneeling in front of you. You're like, “Here, Mike, take this.”
Mike: Because the reducing stigma thing, it's not the cake. It's not even maybe the frosting. It's not a core part of the mission. The core part of the mission is getting fat people to want to lose weight.
Aubrey: So, I did a little YouTube search to see if we could get some of the leaders of the American Obesity Association and hear their actual voices. I think I found something better.
Mike: Oh, no. Are they all CrossFit instructors?
Mike: How bad is it?
Aubrey: I would love it if it was just all the Peloton dudes.
Aubrey: Okay. I'm going to send you a link. This was last year, they did a series of PSAs. The video I'm about to send to you has 28 views. So, I don't know who these PSAs are for.
Mike: [laughs] As someone who used to work at NGOs and made videos for NGOs, I love me an NGO YouTube video with 16 viewers, which they probably paid like $80,000 for. [laughs]
Aubrey: Well, just you fucking wait, Henry Higgins, I think your mind might be blown by how much money they did or didn't pay for this. [laughs] I've got it all queued up, you let me know when you're ready to hit play.
Narrator: Over the past 15 years, there have been over 5000 recommendations and initiatives from the most brilliant minds in America to prevent obesity. All of them failed.
Mike: Oh my God.
Narrator: We have bold, new ideas to be active, to be healthy and to live longer. I hope you will join us at the americanobesityassociation.org. Rethink, renew.
Mike: I love that they couldn't afford Morgan Freeman. So, they got someone who sounds exactly like Morgan Freeman.
Aubrey: Wait, do we not think that that's Morgan Freeman?
Mike: That cannot be Morgan Freeman. With 29 views, this is not Morgan Freeman.
Aubrey: If there's one thing I know about Morgan Freeman, it's that he is box office catnip. There is then clipart of an American flag waving.
Mike: That was one of the ugliest fucking things I've ever seen. This bugs me so much when people use After Effects for evil. It was like clipart of like a CGI waving American flag, and then just a box of text in front of it.
Aubrey: Well, and also the box of text is again, Michael Hobbes’ catnip, which is just like, “The most brilliant people have come up with all these ideas to counter obesity, and all of them have failed, but not us.”
Mike: I know. How long have you been working on this issue again? Who failed?
Aubrey: [laughs] Totally. Who's doing the failing here? I don't have anything against this organization in particular, or this PSA or whatever. But the rhetoric doesn't hold. It's the same fucking rhetoric as diet sales where they're like, “You've tried everything. Now try this thing, that's the same as all the other things you've already tried. Our thing might not fail.”
Mike: We should also mention no country or American state has ever reduced its obesity rate. And no one has proposed like a radical rethink of what we're doing. It is wild. It's like, “No, no, no. Let's continue doing exactly the same things like the billboards, five fruits and vegetables. Let's do it all, just more of it.” And you're like, “Well, it's been 40 years.” And it's not even like it's stalled, it's continuing to get worse, according to your definition of what bad is.
Aubrey: Totally. And at the time, in the 90s and 2000s, these folks from the American Obesity Association are not only doing the, "We've got bold new ideas thing," which is like, “Do you?” They're also making wild ass fucking claims that are not substantiated by any data. Their president will make these speeches and will say things like, “Medicine has never seen an epidemic of this proportion.”
Mike: I mean, smallpox, I don't know.
Aubrey: They're also saying making these broad claims that get repeated a lot, particularly by elected officials saying that, "Because of obesity, children will have a shorter lifespan than their parents."
Mike: Don't get me started.
Aubrey: Demonstrably false, is all I will say.
Mike: Don't wind up my little back and get me talking about that fucking number, which shows up in every goddamn magazine article that's ever been written about this issue.
Aubrey: I'm winding up your back, telling me what you think. [laughs]
Mike: [laughs] Well, how would you even possibly determine this? How would you possibly know that a five-year-old today is going to have worse outcomes than a 55-year-old today? We're literally talking about something that's going to happen like 70 years in the future. It just is like on its face a completely absurd thing to say.
Aubrey: And at this point in the 90s, life expectancies are pretty steadily continuing to climb. There's not really a way to isolate, like "These are the people who are going to become fat. Here's what that's going to mean for their life expectancy." All of that is guesstimating, and again, filling in the gaps with what you believe about fatness and fat people.
Mike: Exactly. The whole thing is like an exercise in math.
Aubrey: Would you like to hear another on its face, completely absurd thing to say that they're saying around this time?
Mike: Ooh. Give it to me.
Aubrey: Their president in 1999, his name's Richard Atkinson, says, “Obesity is the most prevalent fatal, chronic relapsing disorder of the 21st century.” He says this, “Before the 21st century has begun--”
Mike: That's the only thing to debunk there.
Aubrey: Of course, it's totally fatal. People die being fat all the time.
Mike: This is an organization, to recap, that is fighting fat stigma.
Aubrey: Yeah, totally. Prevalent, fatal, chronic, relapsing.
Mike: The fat people you see are walking diseases.
Aubrey: They're ticking timebombs of disease and deaths.
Mike: Jesus Christ.
Aubrey: He says this thing about prevalent, fatal, chronic, relapsing disorder of the 21st century before the 21st century. And what starts to happen is elected officials and appointed officials start to pick that up. David Satcher, who was the Surgeon General under Bill Clinton, releases a report in 2001 saying that, “Obesity is reaching epidemic proportions.” He cites that schools are a key place to fight against the “obesity epidemic.” Again, fucking citation needed, my guy.
Mike: Also, until you come to me with a big fat check for school lunches, shut the hell up about what we're going to do in the schools to fight obesity.
Aubrey: Well, also, one of the things-- this is not part of my notes or whatever, but one of the things that they look at is vending machines in schools in one of the big books that I read. And they were like, “Hey, man, if you want to get vending machines out of schools, if you want to get fast food out of schools, the reason that school districts are signing those contracts is because they are fucking underfunded.”
Mike: Dude, I know. My district got 10 million bucks from Pepsi the year that I was in entering high school.
Mike: I love that obesity is this scourge and it's destroying society and everybody's going to die but it's not a big enough problem for us to spend nominally more money on feeding children. No, it's not that big of a crisis, you guys.
Aubrey: And then, the next Surgeon General is this guy named Richard Carmona, who goes fully like, “Hold my beer. Let me escalate this. How can I escalate this?” In the years after September 11th, Richard Carmona is the Surgeon General. He's asked by a reporter what the greatest threat to Americans’ health is. The way that he tells the story. He's like, “This reporter really expected me to say terrorism. But I said there are two, terrorism is the threat from without, and obesity which is the threat from within.”
Mike: So, you still said terrorism.
Aubrey: It's a threat to our health, Mike. I don’t know what you're talking about. By 2004, he refined this and he says, “As we look to the future and where childhood obesity will be in 20 years, it is every bit as threatening to us as the terrorist threat we face today.”
Mike: That's actually true because the terrorist threat was not that big of a threat and that entire era is extremely embarrassing now.
Aubrey: You're right about both, in that you're wrong about both.
Mike: You were correct with that one, Dr. Carmona.
Aubrey: Now we're not only in an epidemic, we're also in a war. The war on childhood obesity, very chill to make this rhetorical device a fucking child soldiers who are fat kids who have had it too good for too long, [laughs] famously.
Mike: This is also where we get into some good classic moral panic stuff about needing to think of the children. I feel kids get invoked in the debate over obesity a lot in a way that's very weird, because children's eating decisions are the result of their parents and their schools. So, even if we are talking about childhood obesity, we are still talking about adults.
Aubrey: Yeah. But it's just again, like we've talked about this before, projecting all of these adult anxieties on to kids, and making kids the canary in the coalmine about these very adult worries. This also comes on the heels of No Child Left Behind, which institutes this test-based funding approach to schools where you're like, “Oh, it's bullshit all around.”
Mike: Yeah. Also resulted in a lot of cuts to physical education, because you can't standardize that the way that you can multiple choice questions.
Aubrey: Right. This is also around the time, Michelle Obama calls obesity, “One of the greatest threats to America's health and economy,” which is real wild framing.
Mike: It's also not true because we charge people so much for healthcare, that it's actually really good for our economy that we all get-- [crosstalk] Boom. Dunked on Michelle Obama, first time.
Aubrey: Some scholars have charted the overall changes in media coverage around this issue. In 1994, there were 33 national news stories about obesity. In 2000, there were 107. By 2004, there were 700 national news stories about obesity.
Mike: That sounds about right. You remember this, this was what faced us when we opened the newspaper at the kitchen table every morning.
Aubrey: Not only were there news stories about it, that's one thing, but the news stories were fucking garbage. They were super alarmist. They were not really based in super strong science. They would pull one statistic out of context, and then just be like, “Everybody freak out. You're going to get fat and then you're going to die.”
This is a quote on a headline from the Associated Press from Eric Oliver, who wrote Fat Politics, “On January 8th, 2003, the Associated Press ran a story with the headline, ‘Obesity at age 20 can cut lifespan by 13 to 20 years.’ Only later did the story reveal that the obesity in question was at a BMI of 45.” That would be 340 pounds for a 6-foot man, which affected less than 1% of the population. We're getting these big, splashy headlines at a time when a bunch of people have been newly recategorized as obese who weren't before going, “Okay, now you're fat. And because you're fat, you're going to live 20 years less.”
Mike: It's just an invitation to be mean to people. “You're obviously going to die drastically sooner. So, I have to tell you this.”
Aubrey: Yes. And in terms of shaping people's perceptions of fat people, the images paired with a new story matter more than the text of the new story.
Mike: The images, dude. Argh.
Aubrey: The fucking images are brutal. Yale University hosted some research on images used in news media. This was headed up by Rebecca Poole, who's done a bunch of research around weight stigma and anti-fat bias. In this study, they showed people a neutral news story about obesity, and accompanied those neutral news stories with a mix of images of fat people that either leaned into stereotypes or leaned out of stereotypes. A well-dressed fat person and a poorly dressed fat person. A fat person exercising or a fat person eating junk food.
They found two things that I found really interesting. One was that they found that those who viewed the “negative" or stereotypical images of fat people did report higher levels of anti-fat bias. This is around the time when truly every night on the news, there are these deeply fearmongering stories about obesity. And then, there are these shots of fat people filmed from the neck down. Just headless, faceless, fat waistlines milling around. I would argue that those are stereotypical and unflattering. Often, they are fat people sitting down and eating a sandwich from Subway or eating something from McDonald's.
Mike: That’s the thing. It's not just fat people going about their day. It's always them doing something that makes them look slovenly. They're like cigarette in one hand, a burger in the other. It's like they're clearly looking for images that are this person is going to die in the next 10 minutes.
Aubrey: Yes. And they'll also do ill-fitting clothing.
Mike: That’s so bad.
Aubrey: Really and truly, if you turned on the news on any given channel, there was a very good chance that you would see that footage at least once.
Mike: Yes. Fat people are never happy, fat people are never successful, fat people are never just doing normal stuff and not thinking about their weight. It's just that is central to who they are and they look like shit at all times.
Aubrey: I will say during that time, you're asking me like what was this time for you personally, earlier on, I will say during that time, I spent a good 10 to 15 years watching that B roll and I would often tear up watching it because-- ooh, I might tear up now, because I was looking for myself. This stuff is filmed in public. It's filmed without the consent and often without the knowledge of the people in it. And absolutely every time I would look for, “Okay, does somebody have their nails done like mine? Is that my jacket? Are those my pants?” So, I think there's both the dehumanizing effect of the attitudes that very clearly, and again here empirically, stokes in people who aren't fat, and there's the psychic toll that it takes on actual fat people to be like, not only is this an existential threat to me, there is a material moment where I'm like, “They might be using an image of my body that I don't know that someone else took to prove this point, and to make people hate, people who look like me even more.”
Mike: I cannot watch that footage without thinking of somebody coming home from work, and turning on the TV to watch the news and seeing themselves.
Aubrey: Yes. I will also say I've talked to so many other fat people who have the same experience where they're like, “I either can't watch it at all, or when I do I have to watch it so fucking carefully. I have to watch it forensically for any signs that this might be me.” And that is a horrible fucking way to walk around in your life.
Mike: What is the opposite of a Pulitzer?
Mike: What can we do to news organizations that’s [crosstalk] [laughs]
Aubrey: A Poo-litzer?
Aubrey: My single worst joke I've ever made. I would call it a dad joke, but that is disrespectful to dads.
Mike: I just think that there should be some sort of gang of fat people that put on masks and drive around in a van and find the people that take that footage and just smash their camera on the ground [crosstalk] piece of shit.
Aubrey: Just vigilantes.
Mike: I fucking saw you with a tripod.
Aubrey: [laughs] I love this idea. Can I tell you about their other finding--?
Mike: Yeah, do it.
Aubrey: Related to ant-fat bias, in this particular study around news media coverage? This is not a global or representative study, lots and lots of asterisks here. This is a relatively small study, it was designed to find out something else. But in the process, they went through the results on the “fatphobia scale.” They found that anti-fat bias in this sample wasn't correlated to income, it wasn't correlated to age, it wasn't correlated to race or ethnicity, gender. What it was correlated to was body size. The thinner you were, the more likely you were to express bias against fat people. It feels important to say because I think many, many people who don't have the social experience of being perceived as fat or the institutional experience of being perceived as fat, tend to think why don't mean fat people harm. I'm not going around yelling at fat people, like, “Hey, fatty, put down the burger.” That's not actually how anti fatness appears in many fat people's lives. It appears much more often in family members being like, “Hey, do you want to work out, buddy? I'd be happy to pay for your Weight Watchers membership. How can I help?"
Those things are also markers that someone is monitoring your body, that the size and shape of your body is wrong, that you are being judged, and that you need to take corrective action to get back in that person's good graces. One of the biggest things that often stands out on the fatphobia scale and is correlated to a bunch of other negative beliefs about fat people, is simply the belief that fat people can control their body weight. If people believe that, they believe a bunch of other really horrific things about fat people.
Mike: In the same way that scientists don't want to admit what impact they want to have on the world, I think journalists are totally disincentivized to actually look into the way that their work is affecting public perceptions and the experiences of actual groups in society. One of the things, one of the actual categories, when you apply, when you send in one of your magazine articles to win a Pulitzer is impact. We expose this evil used car salesman, and then they passed a law, saying that used car dealerships can't do this. Meh. We are told to highlight this, that we want to have an impact in the world.
But journalists are not trained to actually take seriously their inadvertent impacts. Most of the impact of journalism is not deliberate. It's just myths that we reinforce, it's images that we use, it's bad headlines with all of the caveats taken away. Journalists affect public perceptions in ways that they actually need to take seriously. If you've taken this B roll, you should feel bad. I'm sorry. I'm not going to send Aubrey in a van to your house, but you should feel bad.
Aubrey: No, I think the concern that people should have is Mike in a van to your house. [laughs] I feel you would get-- I would just be real sad and be like, “Why would you do this?” I feel you might actually bring a baseball bat. [laughs]
Mike: And I’d be on a bike too, so I can get away that fast, is the problem.
Aubrey: [laughs] To this point on what's the impact of this media coverage, as it stands today, according to Harvard, 80% of Americans express some level of anti-fat bias.
Mike: Ooh, that's bad.
Aubrey: They have pretty precise data on the increase in anti-fat bias around this time of the peak of the obesity epidemic. They found that between 2004 and 2010, while many other forms of bias were declining, anti-fat bias rose 40%.
Mike: Sometimes, we can be a little bit salty to people who are really invested in this narrative. But also, this is what people have been told for decades.
Aubrey: Totally agree, that you can see where it comes from. They're not opting in to being terrible to fat people, they are being fed a narrative that is essentially, like, “You have to be mean to fat people for their health, because they don't know that they're fat. And they don't know that they're going to die, and you've got to be the one to tell them,” which is a very direct seeding of practices of bias. It's not necessarily their fault that this is the framework that they're using, but they are still acting on that framework in ways that are really awful.
Mike: Yes. My approach to those people is to be very polite and patient in real life, and then very spicy on my podcast. I will go on a journey with you. I will calmly walk you through the fact if we are friends, and we are talking, I will be patient, I will listen. And if you're some random person on Twitter, I'm going to shout at you. I'm sorry.
Mike: I'm not going to be patient that way.
Aubrey: We've got this fallout in media. We've got this shift in funding for research in an academic discourse around a “obesity epidemic.” We also have some fallout in policy interventions. We start changing school lunches. We start requiring in some states a certain number of PE hours in order to graduate from high school. We start sending out BMI report cards to parents of school-aged kids saying, “Here's your kid's BMI.” We start adding calorie labels to restaurant menus. Because obesity rates are by design higher in communities of color, we start funding community-specific projects to prompt weight loss. Particularly in black communities, there's significant investment. We can debate whether or not each of those are worthy policies on their own. The fact remains that not one of these are proven strategies to prompt weight loss.
Mike: It's also frustrating because there are proven interventions that improve people's diets and exercise relatively reliably, but because we have this narrow focus on weight as like the only metric that matters, we're not moving the metrics that we actually can move. We're trying to do the hard thing and leapfrogging the easier things.
Aubrey: Around this same time, speaking of the easier things, in 2006, the Alliance for a Healthier Generation, which is a collaboration between the Clinton Foundation and the American Heart Association, make this big announcement. They're joined by representatives from Coca-Cola, from PepsiCo, from Schweppes, and from the American Beverage Association, to announce that they're going to start removing soda from schools.
Bill Clinton and Mike Huckabee both point to this as a sign of this extraordinary investment from the business community in public health, that they're willing to forego their own profits and their own customers. What is not mentioned in that press around this is that these beverage manufacturers are facing a massive lawsuit from the Center for Science in the Public Interest. As part of this agreement to pull soda from schools, that lawsuit is dropped. Around the same time, McDonald's is facing a class action lawsuit from fat plaintiffs. The argument of that lawsuit is McDonald's has been making addictive and fattening food blah, blah, blah. In 2005, there in a bill introduced in Congress called The Personal Responsibility in Food Consumption Act.
Mike: [laughs] Wait, does that stand for prick? What does it stand for?
Aubrey: No, it would be PRIFCA, which is not as good.
Mike: Oh, PRIFCA, all right, never mind. Do better, Congress.
Aubrey: It was referred to in the media as, I shit you not, the Cheeseburger Bill. It was specifically designed to prevent consumers from suing fast food restaurants.
Mike: That does honestly seem a frivolous lawsuit, to be totally honest. But also, we're now losing our rights to sue companies like that, that's not a good outcome.
Aubrey: I'm not on board with either of these lawsuits necessarily. Both of them seem kind of stigmatizing to me and weird. You what I mean? Like [makes weird noises]. But it does feel telling to me that at the same time that it looks like we're doing these great altruistic things, what most of them amount to is protecting corporations from some sense of accountability for their contributions here. It's also worth noting that the Cheeseburger Bill was introduced by a Florida congressman named Ric Keller, who had received the maximum legally allowable campaign contribution from McDonald's.
Mike: Yeah. I can feel the tinfoil hat crinkling around my head right now. It's like metal in my ears.
Aubrey: The last thing I wanted to talk about here, and this is something that you and I have talked about a little bit, is around the social science and theory of moral panics. There is an argument to be made here, and it has been made many times by many scholars and many researchers. This is something that has not really made it into the mainstream. While there are observable trends that people may be getting fatter over time, I would argue and many of these scholars would argue that our response to that observable thing meets a lot of the criteria for a moral panic. There's this sociologist named Stanley Cohen, who writes a book called Folk Devils and Moral Panic.
Mike: Yeah, I have read that. It's great.
Aubrey: It's so good. He lays out these sequential phases of a moral panic. And then in 1994, Erich Goode and Nachman Ben-Yehuda establish five characteristics of a moral panic. One, concern, where there is a heightened level of concern about certain groups or categories. Two, hostility, where one can observe an increase in hostility toward the “deviance” of “respectful society.” Three, consensus, where a consensus about the reality and seriousness of a threat can be found. Four, disproportionality, where public concern is in excess of what “should be.” And, five, volatility, where the panic is temporary and fleeting, and though it might reoccur, the panic is not long lasting. To my mind, I think our response to the obesity epidemic checks a number of those boxes, but not quite all of them.
Mike: Yeah. I think it's been going on too long for it to have the volatility aspect. Although even within moral panics, there's like a topology about how long lasting they are, and the kinds of reactions that they inspire, because another interesting thing about the obesity epidemic, I don't know that the response has been disproportionate, because the response, the actual legislative response to it has mostly been dumb bullshit nudge things, like these calorie markers. To me, it gives a lie to the entire thing, because if we actually took this seriously, we would have done something, but we haven't actually done anything meaningful on this issue. We've just panicked about it.
Aubrey: Yeah. I think part of that disproportionality, one, to my mind, is what's the set of questions that you ask next. We really seem to have skipped over a whole lot of those clarifying questions. What is the precise relationship between weight and these specific health markers? Who does the “obesity epidemic” affect? There's quite a bit of data that shows that it's predominantly a problem amongst men, but a bunch of our solutions, policy solutions are aimed at women. There's all of these things that if we were curious about the nature of this thing, we would ask a bunch more questions, but we're not curious about it. We're just like, “Kill it.” [laughs]
Mike: Yeah. In my own personal definition of moral panics, something that I see very clearly in the obesity stuff, the evidence just isn't there, and the evidence isn't there in this extremely obvious way. So, it's like we're constantly debating the health effects, like does it affect cancer? Does it not affect cancer? Obesity and health are just as two concepts so closely linked, but it's all irrelevant, because the data is more consistent on the fact that people cannot lose weight and keep it off, than it is about fat being bad for them. Even at the individual level, we cannot solve this problem. And then it's like it's possible to write an entire 2000-, 5000-word magazine article on the obesity epidemic and all these new solutions, when it's like people can't lose weight. Why are we talking about this? Everything else is secondary to that. We should just learn to live with the big people that we have. That's it.
Aubrey: I think there's even a conversation to have about, even if we have effective strategies for weight loss, how do we deploy those strategies and who they're aimed at, and all that kind of stuff. Unless and until we have those strategies, every fucking thing we do around this is punitive. All of this stuff is designed around reminding fat people that we're fat, reminding fat people that being fat is bad for you, and just making us sort of wear this kind of hair shirt in the absence of any real solutions.
Mike: One way to look at moral panics is it's these real fears that get projected on to a minority group. The obesity epidemic has been a very effective moral panic, in that it has distracted us from heart disease is the number one killer of Americans, things like diabetes is a pretty debilitating condition and it causes a lot of pain and hurt in people's families. I think that the institution of public health should be trying to solve these problems. But instead of actually focusing on what are the real problems staring us in the face, it's like we push all of this on to fat people. We should have just been having not a moral panic, but a regular normal level of concern for these diseases that are really difficult to have.
Aubrey: It's not a moral panic, but a regular panic, is really what I thought you're about to say.
Mike: A decent panic.
Aubrey: Yeah. Listen, if we're concerned with the impacts of living with diabetes and we want to alleviate those impacts, then we could very well do something that is hard, but not complex, which is cover insulin for everyone who needs it.
Mike: Dude, insulin, there should be fire hydrants of insulin on every corner. Michael Hobbes, 2020. That's such a perfect example though, where it's like we're so concerned about diabetes that every single fat person needs to get a goddamn lecture at the grocery store. But we're not concerned about it enough to fuck with the patents? Do we care about this issue or do we not care about this issue? Because it seems like we don't actually care about this.
Aubrey: If we care about diabetes, we need to take on diabetes. If we care about heart disease, we need to take on heart disease. But right now, what we're taking on is a thing that is a sort of a proxy risk factor. And we're taking it on in part because we've already decided what we think about fat people and how that came to be fat, regardless of the data. And I’ve got to say, it's extremely shitty to live in a world where people's imagination of the healthiest and best world possible doesn't have people who look like me in it.
Mike: Yeah. Fat people have always been collateral damage in this entire debate. I can't see any of the public health campaigns that we've had, anyone even thinking whether they consulted fat people or not, even thinking about like, "What would it be like as a fat person to encounter this?"
Aubrey: Yes. Even just imagining.
Mike: Yes, very basic questions are not being asked.
Aubrey: Listen, man, I feel that is the story of this genesis of the obesity epidemic. This is not the smoking gun story that we got with the BMI. It's much more a story about these very human flaws, like filling in the gaps of what we think we know with “common sense” that just ends up drawing on our own existing ideas about who fat people are and how fat bodies work. We tell ourselves stories that strike familiar chords and that comfort us about the world and our role in it. Those stories are very comforting to thin people to be like, "Fat people are unhealthy. And as long as I'm not fat, I don't have to worry about my health," which is also not true. It feels like a real story of a kernel of science, and then a whole bunch of social narratives that grow up around that kernel of science.
Mike: Yes. And as we know from history, the only way to solve issues like this is for four to six fat people to get in a van and find a local cameraman in your area who took B roll that day, and smash his camera to the ground and set it on fire.