For nearly four decades, Americans have heard a simple story about health, longevity and obesity. This week, we learn it's a little more complicated.
Thanks to Katherine Flegal, Paul Campos, Jeff Hunger and Jason Salemi for helping us research and fact-check this episode!
Aubrey: Hi everybody and welcome to Maintenance Phase, the podcast that's just concerned about your health.
Mike: Oh, my God.
Mike: Or in your mentions on Instagram, you're glorifying it.
Aubrey: [laughs] that one really lived or died by the line reading and I feel pleased with how it turned out, if I'm honest.
Aubrey: I'm Aubrey Gordon.
Mike: I'm Michael Hobbes.
Aubrey: This month by astonishingly popular request, our bonus episode for Patreon patrons at every level is the HBO Max documentary miniseries The Way Down.
Mike: Yes, I've been told that I have very disappointing opinions on this matter.
Mike: So, enjoy those. Today, we are talking about, is being fat bad for you?
Aubrey: I'm both very excited for this to get the Michael Hobbes, like terrier digging through a million facts kind of treatment. I am also nervous about it because this is the kind of thing that people with profound anti-fat bias use against fat people all the time. Anytime you open up this conversation, it's like opening up Pandora's fucking box-
Mike: I know.
Aubrey: -for fat people.
Mike: This little intro is so telling, I think because the way that fat people and thin people experience this conversation is worlds apart.
Mike: Thin people experience this conversation as like, “Well, I read a Newsweek the other day because everybody's fat, we're all going to live 13 years less than we thought we would.” And fat people experienced this as like, “You are going to die.”
Aubrey: Yes. I would say fat people experience it as you are going to die because often thin people who read those Newsweek articles, then turn around and tell fat people, “You are going to die.”
Aubrey: When a thin person decides to tell a fat person, “We're going to live 13 years less or whatever, because you're fat,” whether or not that thin person intends to do so. The idea that that introduces is, “I'm superior to you because I have figured out how not to do this thing and you are failing because you have not figured out how to do this thing.” Anti-fat bias has, I would argue a more decisive impact on fat people's health than actual just physical body weight.
Mike: Then adipose tissue.
Mike: A term that I have read far too many times this week. Yes.
Aubrey: [laughs] All right. This is so many caveats.
Mike: I know let's keep caveating, just never start.
Aubrey: Let’s never start and only be like, “One more thing before we get into it.”
Mike: [laughs] My friend has this joke that every left-wing podcast is just people saying, “I'm just going to zoom out for a second,” over and over again.
Mike: That's what we're doing.
Aubrey: Oh, no, that’s me.
Mike: To me I think a really important, God, I'm doing it, aren't I, contextualization-
Mike: -thing about this issue is people, most of the academic literature treats this as some sort of footnotes. But to me, it's very important to acknowledge that stigma against fat people and the belief that fat people are unhealthy, long predates any science showing that. This really good book called Fat: A Cultural History of Obesity, where they identify the first reference of an obesity epidemic was in 1620. The Catholic Church invented the Seven Deadly Sins, and one of them was Gluttony.
Aubrey: And sloth.
Mike: Well, exactly, yes. There's always been this moral component and there's always been this out group component. Something I didn't know until I read this book was that diabetes used to be known as the Jewish disease.
Mike: The idea was, there was something about Jewishness that gave people diabetes, it was like a genetic predisposition basically.
Aubrey: Oh, boy.
Mike: This has always been associated with like, this is a group that I do not like, and I'm going to assign to them like some sort of health status.
Aubrey: If we think back to the BMI episode, the earliest connotation of the BMI was the fattest 15% of people would be considered overweight. It didn't have anything to do with health risks. It didn't have anything to do with anything, but the fattest among us need to be defined in this way. Then you create a bunch of funding streams to find out why it's so unhealthy and so terrible to be what we already think of as terrible.
Mike: It can sound a little bit conspiratorial to be, like, “Everybody hates fat people. And that's why all the science says this.” I do think that that's overly simplistic. But I also think that it's also overly simplistic to think that this has no effect. The earlier studies of what does it do to your health to be a fat person? I'm going to skip a lot of this because we talked about it in our BMI and obesity epidemic episodes, but the only data that was available was from life insurance companies.
Aubrey: This is the 40s, 50s era.
Aubrey: Think about who had excess income in the 40s and 50s to spend on life insurance. It's going to be disproportionately white, overwhelmingly male, middle class, upper middle class, and straight up wealthy. There's a whole wide, wide range of people that you're missing.
Mike: Exactly. Basically, the big innovation at this time and the closest thing we get to reliable information on fat people and health, is the rise of the cohort study. Are you familiar with this?
Aubrey: Uh, no. I know cohort studies exist, [both chuckles] but I don't know what the rise of them.
Mike: [laughs] I'm not fucking with you.
Aubrey: I feel like I'm being trapped somehow.
Mike: Basically, everyone knows these life insurance tables are bullshit for all the reasons you just said. What they start doing in the 1940s and 1950s is they start getting these large groups of people and they get a representative sample of the country. They start getting together an entire small town. One of the most famous ones is a bunch of nurses. It's like 70,000 nurses, huge numbers, and then you track the same people over time.
Aubrey: Yeah. It's essentially like the Seven Up! Series, but in science.
Aubrey: That's like, “We're checking in periodically. We want to see how you're doing on these specific sets of measures.”
Mike: Yes. After a couple of years-- after longer periods, some of these cohort studies have been going for decades at this point. Once you wait long enough, people start dying. And then you can get into all of this risk relative, mortality rates rising kind of thing of, okay, so why if we would expect 25 deaths? Why are there 50 deaths among fat people? That is how you can start doing these gradations and figuring out what is killing Americans.
The central issue with calculating these mortality rates is, you can't just look at the raw numbers. So, if you say if we look at normal people, 500 of them died. But then if we look at smokers, a thousand of them died. Smokers are twice as likely to die. But that's too simple, because smokers are not the same as nonsmokers. Smokers are much more likely to be poor, they're much more likely to be uneducated, they're more likely to be unemployed, they're slightly older than the rest of the population. There're all these other factors. So, you have to adjust, so that you're comparing like poor uneducated smokers, to poor uneducated nonsmokers, and then you can say, “Ah, okay, so this is what accounts for, the smoking.”
Aubrey: Right. If you don't do some level of statistical control then you do what your brain is wired to do, which is fill in the blanks with what you think you know, which are often not rooted in data or science or anything.
Mike: Exactly. What you just said is basically the Rosetta Stone for this entire episode because if you look at the raw numbers, it's true that very fat people have shorter lifespans than thin people. It's complicated for the lower weights, and there's a lot of scientific debate about sort of when that association kicks in, and we'll get into it. But that correlation, that statement that very fat people are more likely to get heart disease and diabetes and everything you've read about in a million Newsweek articles, that's never really been debated. The debate is about what the association means because obesity is not the only thing that's associated with having a shorter lifespan. Catholics live two years longer than evangelicals, and Jewish people live two years longer than Catholics. People who live in West Virginia die six years younger than people who live in California. One of the weirdest statistics I came across is that people with master's degrees have 10% higher mortality rates than people with PhDs.
Mike: Next time you see somebody posting about like, “Hey, I got my master's degree on Instagram,” go into their mentions, like, “You're glorifying in having master's degree.”
Aubrey: I'm just concerned about your health.
Mike: I know.
Aubrey: Quit your master's program.
Mike: Another really consistent one is that unmarried people have between two and two and a half times the mortality rate of married people. What I love about the unmarried statistic is that when you tell people, okay, unmarried people are more likely to die, you can see the gears in their brain start working. People are like, oh, it's probably something to do with, like, if you fall down the stairs, if you're a married person, like someone is there to call 911 or maybe somebody is going to hassle you about getting a doctor's appointment for like the lump in your chest if you're married, whereas if you're not, you might just like leave it for another year. People will start speculating about what the sort real reason is for this association, because we all on a gut level understand that having a piece of paper, the marriage license is not extending your lifespan.
Aubrey: This is also how you get that fucking garbage ship that will show up in like People Magazine is like a pullout box. That's like, “Dog owners live five years longer than people who don't own dog.” “People who own subcompacts have longer happier lives than people who drive SUVs.” Like all of that utter garbage comes from either findings that are not great or people not digging far enough into the findings before translating them into popular media and then popular media running with that shit.
Mike: Exactly. No one looks at all these other associations and immediately leaps to, “Oh, this is how we have to fix it.” Nobody is saying that, no matter what you go into the doctor for, they should be like, “Ah, have you considered converting to Judaism?”
Aubrey: Yeah. [laughs]
Mike: This isn't actually a difficult concept for people. What's difficult is that we have been told this extremely simple story about obesity for so long, that it's really hard to look at it any other way. And the thing you have to constantly remind people of, is that obesity is not a behavior. Obesity is a characteristic. People become fat for all kinds of reasons and people live their lives as fat people with all kinds of habits. There are fat people who don't get any exercise, there's fat people who get tons of exercise. There are skinny people who get no exercise. There are skinny people who get tons of exercise. These are all overlapping circles. The entire debate over obesity is where on the spectrum does it fall. Is obesity more like smoking? It's a behavior that we can very clearly link to causing all of these health problems and shortening your life? Or is it more like having a master's degree? Where it's like, okay, it's basically a cluster of other correlations.
Aubrey: Yeah. First of all, this is about to be maybe our methodology queeniest episode, I'm getting the sense.
Mike: Methodology Empress, Methodology Galactic Senate.
Aubrey: This is the project of creating and reinforcing an outgroup status and making people believe that it is objective, that it is scientific, that it is beyond reproach, and that it is natural for you to feel like fat people are lazy and gross, because that's what they are because science tells you they are. It's just bizarre that we try and take this stuff in a vacuum and just parrot it out as gospel.
Mike: This is the hardest thing about this, is because you have to keep in mind issues outside of the data. One of the most famous findings from these, is in the 1990s, the Journal of the American Medical Association published a study that said that left-handed people die nine years younger than right-handed people.
Aubrey: [laughs] What?
Mike: This was actually something that I was told growing up because I'm left-handed and my whole adult life, I've been thinking about like, “Why am I going to die so young?” There's these like crackpot theories about like driving. The stick shift is with your right hand or something.
Aubrey: But also, who drives stick anymore?
Mike: I know. It makes no sense.
Aubrey: I don’t know, man.
Mike: What it actually turns out is essentially, the researchers looked at the population of 70-year olds and they said, “Okay, well, there's roughly 12% of the population is left-handed.” And then they looked at seven-year olds, and they're like, “Oh, my fucking God, only 3% of these people are left-handed.” So, all of the left-handed people must have died. It's like they're dropping like flies [laughs] and we're only left with this much smaller population. But, of course, these are some of those scathing letters to the editor of a medical journal that I've ever read. All of these people write in and say, if you're looking at a population who's in their 70s, in the 1990s, these are people who grew up in the 20s and 30s. And in the 20s, and 30s, if you wrote with your left hand, they would make you write with your right hand. So, the reason why there are only 3% left-handers in that age cohort isn't because there's like a genocide of left-handed people. It's because due to other social forces, the rate of left-handed people is like artificially low among old people.
Aubrey: I will tell you this, my grandfather who passed away 15 years ago-ish was an extreme left-handed pride guy. The level of vindication that this guy is getting posthumously is through the roof.
Mike: Aubrey, all hands matter. I don't know why he was being so rude about it, all hands matter. All hands, fuck.
Mike: The left-handed thing, first of all, I just have kind of a chip on my shoulder as a left-handed person about this, but also it's just important that you can't only look at the data. That data about left-handed people, you can slice and dice it, you can control for smoking status, and you can do all kinds of statistical mumbo-jumbo on that data, but it's only going to drive you to a slightly less boneheaded conclusion. This leads us to meet our protagonist for this episode.
Aubrey: Oh. We have a protagonist.
Mike: Yes. A woman named Katherine Flegal.
Aubrey: Oh, sure.
Mike: You know this.
Aubrey: Oh, my God, Mike, I'm so excited. I forgot about this.
Mike: All right, put us in space and time. Who is Katherine Flegal and what is going on in the late 1990s?
Aubrey: Katherine Flegal is a statistician who works at the CDC and I know that she waited to tell this story until after she was retired.
Mike: Yes. Katherine Flegal is at this time a statistical researcher for the CDC, she got her bachelor's from UC Berkeley, she did a PhD in nutrition at Cornell, her work has always focused on obesity. And she's one of the first people to notice, like, “Hey, Americans are getting fatter.” She's one of the first people to start publishing on this. And she was actually in, I believe it was Geneva at that WHO meeting where they changed the BMI categories.
Aubrey: Oh, whoa. Holy shit.
Mike: She is deep in this field and one of the earliest people, just trying to get the message out that something is changing in the American population and people are getting fatter. In the year 2000, she starts working on a paper about obesity and health. She's been in the CDC for a while, there's this long-standing debate about like, what does it actually mean for your health to be fat. And she decides to start looking into this in a very conservative way, like, “I'm going to find the best data. I'm going to try to really answer this question once and for all.” What she does not know is elsewhere at the CDC, another team is also working on this. In 2004, we get the infamous paper that is called Years of Life Lost to Obesity. We've talked about-- We've debunked this like four times on the show already. It's basically this big CDC study that makes huge headlines everywhere for saying that obesity causes 365,000 deaths per year. It also says that obesity is poised to overtake smoking as the number one cause of death in America.
Aubrey: This is a level of deaths that you would know someone who died just of fat.
Aubrey: That is a very large number of people to just keel over because of their fat-
Aubrey: -which is the impression that certainly that the general public is left with after the reporting on this.
Mike: This paper comes out, gets a ton of media coverage. Less than a year later, Katherine Flegal puts out her paper and in her paper, instead of showing that obesity causes 365,000 deaths a year, her paper shows that obesity causes 112,000 deaths, but it also reduces deaths by 86,000 because slightly overweight people are actually less likely to die.
Aubrey: Right. This is what they call The Obesity Paradox, which is my favorite thing to yell about, because it's only a fucking paradox if you can't imagine fat people living healthy lives.
Mike: Katherine Flegal has some very salty papers about the obesity paradox.
Mike: She's like, “it's not really a paradox. It's just like, maybe it's just not universally bad for you, maybe it's complicated.
Aubrey: Totally. It's not really a paradox. It's just you assumed this wasn't possible, then researchers actually looked into it, and it is possible-- [laughs] calm down.
Mike: Exactly. Sometimes you'll see scientists just rejecting this out of hand, they're like, “Oh, there's no biological mechanism that would make fat people live a bit longer.” And it's like, “Really, you don't see any reason why people who carry around extra energy on their bodies would live longer from certain conditions?” I actually don't find this difficult to believe at all. Considering how many diseases cause you to sort of waste away as you get older, it makes sense, they would live longer from some of these conditions. And that gives them more time to recover. There're also actual studies on this. 80% of deaths in America are of people 70 and above. One of the most common causes of death and disability in old age is falling down and breaking a bone, especially breaking a hip. One-third of people who break a hip die within a year. This sounds really facile, but fat people just have more padding on themselves.
There're actual studies that find that the skinniest people are the most likely to die after suffering a hip fracture. Once you get into the actual causes of death and you're actually curious about this phenomenon rather than simply rejecting it. It's like, “Oh, yeah, it actually makes a lot of sense that under certain circumstances for certain people being a little bit fatter is actually better for mortality.” Basically, the number one finding of her paper is that like people in the BMI overweight category are slightly less likely to die. So, a little bit of fat has some protective effect on mortality rates. The other big finding is that skinny people are more likely to die.
In the fattest category, like the obese category, she logs 26,000 deaths. In the skinniest category, she logs 33,000 deaths. One of the quotes that goes around about this, this is how it ends up in the mainstream media coverage of it is, given current government guidelines it appears that the average person is better off being 50 or even 75 pounds overweight than five pounds underweight.
Aubrey: This is a thing that also gets sort of thorny. It's worth noting very thin people are more likely to die than very fat people and there is no cause for you as a lay person to then start talking to very fat people or very thin people about how they're going to fucking die.
Mike: I like it when you stand up for thin people.
Aubrey: [laughs] Won't someone think of the thin? [laughs]
Mike: I like it when you say thin rights. There're all kinds of actually cohort studies that show the same pattern of this weird spike for thin people, a little bit reduced mortality for people that are like a little bit overweight, and then a higher curve for people that are fat. They call it the U-shaped curve, even though it's like more like a Nike swoosh, but it's an extremely consistent finding in this kind of research. We now find ourselves in 2005. There's this 2004 paper that finds that obesity is really bad for you, overweight people are going to die, fat people are totally going to die, it's just really, really, really obvious deep line, and we've got 365,000 deaths caused by obesity every year. And we've also got Katherine Flegal’s 2005 paper that says it like, “It's really not that many people. Once you subtract the lives that it saves from the lives that it takes, it's like 25,000 deaths a year due to obesity.” And there's this weird thing with like skinny people being less healthy. It seems actually, it would be like good, to be like 5% to 10% overweight. There're now these two papers, both of which are from the CDC saying completely different things.
Aubrey: Right. One estimate is 90% lower.
Mike: Yes. To this day, this is still framed as a scientific debate and two different ways to look at obesity data and who can say? But the important thing to know about these two estimates is that one of them is wrong.
Mike: Like wrong, the first thing that happens with that 365,000 estimate is that people look into the numbers and there're errors.
Aubrey: Just like straight up transcription errors.
Mike: They put the deaths in the wrong years. Human error in Microsoft Excel. Also, there's weird methodological stuff. Remember how I said earlier that when you look at tobacco deaths, you can't just like count up the smokers that die because you have to control for all this other stuff because it's not a representative sample of the population. What they did in this study, when they say obesity is about to overtake tobacco, they adjusted the tobacco deaths downward because, well, people who smoke are more likely to be poor. We have to artificially make that number smaller to make it more valid, but they didn't do that with obesity deaths.
Aubrey: Right. Struck by lightning, congratulations. If you're fat, you died of obesity.
Mike: Yeah, this is literally the sophistication of the analysis, basically, right?
Aubrey: It's astonishing that this number clawed its way into the popular imagination.
Aubrey: And still gets repeated in nonacademic sources all the fucking time.
Mike: I know, I know.
Aubrey: I got a factsheet from a lobbying organization, in the last three months that was, “360,000 fat people die of obesity every year.” And I was like, “Excuse me. What?”
Mike: The earlier study also-- I can't believe they did this, some of their cohort studies ended in the 1970s. Some of the deaths were in 1970s, even though this paper is being published in 2004, but the heart attack, cardiovascular death rates in the 1970s were sky high. You're actually much less likely to die of a heart attack as a fat person now than you were as a normal weight person in the 50s and 60s. If you look at the death rates, they've all been declining for years, even as the population has gotten fatter.
Aubrey: Right. A lot has happened in technology and medicine since then.
Mike: Right. The other problem with these studies is that they're built exclusively around BMI categories. So, every single person in these big cohort studies is organized in normal way, [unintelligible [00:24:07].
Aubrey: Wait, can that be your canonical BMI voice?
Mike: Every time I say a BMI number, I just cringe inside. Also, every time I say obese, I also cringe, I hope that it's clear for my general tone and personality that I'm putting giant quote marks around these terms at all times, normal weight. I don't believe in these things. But it's just going to be much easier if I don't have to say quote unquote every single time. I use one of these adjectives, so I feel deeply weird about like the way that I'm speaking about this issue right now.
Aubrey: I will also say many, many fat people experience the terms “obese and obesity” as slur.
Mike: Yeah, it's so bad.
Aubrey: I've talked to one fat person ever in my time of doing this project where I've talked to thousands of fat people who are like, “I feel neutral about the word obesity.” Everyone else has said, “I feel deep shame about it. I feel I'm being judged. I feel horrible. It makes me think about self-harm.” I think there's this belief that because it's a medical term, it can't hurt people. Lots and lots of medical terms hurt people.
Mike: But they're saying person with obesity now.
Aubrey: Ah, fuck. Michael, someone corrected me on Twitter and was, “Actually what you should be saying instead of fat person is person with obesity.” I was, “Get out of my mentions, you gremlin.”
Mike: The worst is a person with overweight. It's like, what?
Aubrey: It's so weird.
Mike: The problem with these categories for mortality research is that a lot of those cohort studies rely on self-reported BMI. So, you ask people their weight, you ask people their height, and then you calculate that they're overweight, or their normal weight, or whatever. The problem is that when you do this, a huge number of people end up in the wrong categories because people, I don't want to say lie about their weight because a lot of people don't know, accurate-- I do not know my weight. I have not weighed myself in five years. If somebody asked me my weight, I would be wrong. But then the problem with self-reported data is skinny people will lie a little bit about their weight. If you're 150, you'll say you're 145. But if you weigh 400 pounds, you'll say you're 325. The larger you are, the more weight you will take off. But then there's also weird confounders that skinny men will add weight to themselves, they'll say that they're 185, when they're actually 160.
Aubrey: Right. What you're telling right now is the story of my first driver's license.
Mike: Yeah, where they ask you your weight and they don't weigh you.
Aubrey: Yeah, totally. I was like “250 pounds. Don’t worry about it. [crosstalk] [laughter] Just leave me alone.”
Mike: Let's say you have two people, and they're both 5’8” and they both say that they're 180 pounds. So, that's the data in your spreadsheet. But in reality, one of them is 185 pounds, and they're cutting a little bit of their weight off. The other one is 200 pounds, and they're cutting a little bit more of their weight off. In the actual numbers, this isn't actually that big of a deal and people who defend self-reported data, they'll say like, “Well, when people lie about their weight, on average, they only really lie by, whatever 2%, 5%, 10%, something like that. It's not that big of a deal.” But it's not actually about how many pounds they're cutting off of themselves. The problem with those two people is that the cut off between overweight and obese is 190 pounds. The person who's 200 pounds, who says that he's 180, he just jumped from one category to the other.
People have actually done studies where they compare data that's self-reported and data that's actually measured. Some of these studies, the normal weight participants, 30% of them should have been classified as overweight or obese. Look, the BMI categories are bullshit and this has nothing about people's individual health. I don't want to make it sound like I'm giving any credibility to this. But the entire purpose of these studies is comparing people in different categories to each other. If you're comparing dogs to cats, and you're like, “Oh, 30% of the cats in our sample are actually dogs. And we have no way of knowing which cats those are,” which ones are actually dogs in disguise. Your entire study is garbage because you're not actually comparing different categories.
Mike: Another reason why Katherine's study is better than the earlier study is that she throws out all of the self-reported data. You can't just mix bad data and good data and then say anything valid about a phenomenon. Again, this is framed as a scientific debate like some people say 365,000 deaths. And then this wacky Katherine Flegal lady says it's like way smaller. But the CDC corrected the 365,000 number, they put out explicit guidance that they weren't going to use it. In a press release, they say like, “Yeah, we're no longer standing by this number. We are standing by Katherine Flegal’s work. It's just better data.
Aubrey: Right. She didn't write a bunch of conclusions based on typos.
Mike: [chuckles] Yeah, exactly.
Aubrey: That's the thing that is like wild to me about this whole story. It's not like not as methodologically sound. It's like total nonsense.
Mike: This is where the obesity epidemic as a moral panic is really instructive because the pattern that you see in moral panics over and over again is what do we not need evidence to believe. What are the overall societal narratives for which we will put aside, these pretty basic methodological considerations. We won't apply as much scrutiny. The CDC and the Journal of the American Medical Association and these like very high-level public health institutions were willing to print something that in the methodology says, “We are assuming all deaths of fat people are because they are fat.” Yeah, they were just like, “Yeah, sounds good.”
Aubrey: It's astonishing. No one caught or seemed concerned with this very, very boring bold statement of bias. There's no other way to talk about that statement, that a statement of bias.
Mike: Despite the fact that Katherine Flegal’s paper is just like better than the previous paper. There is huge backlash. This is where we meet the antagonist of the episode. Are you familiar with somebody named Walter Willett?
Aubrey: I wasn't six months ago, but I absolutely am now.
Mike: What do you know?
Aubrey: What I know about Walter Willett is that he worked-- does he still work at the Harvard School of Public Health?
Mike: He was at this time the chair of the nutrition department at the Harvard School of Public Health. Yeah.
Aubrey: I feel everything I know about him is a spoiler for this story and through the weird Twitter explosion of people being like, “Oh, yeah, I work on a different issue and he did this to me too.”
Mike: That’s a good week on Twitter.
Aubrey: It was a great week for you and me specifically. [laughs]
Mike: Like, methodology fight. Eww.
Aubrey: For a month, this dude was my Rachel Hollis, that’s what I would say.
Mike: Walter Willett is extremely prominent figure in public health. According to some accounts, he's the most cited nutritionist in the world. This is very important, he also came up with that generation of public health people who are like screaming about obesity for years and nobody was listening. And then once people started listening, I think it left a lot of people in that generation with a chip on their shoulder of, “This is my issue. I was talking about this before anybody else was.” They really want to guide the way that this issue is framed for the public. He also has really bad attitudes about weight and about fat people.
During the events that are about to ensue, he gives a bunch of interviews. One of the quotes he says, “Next to whether you smoke, the number that stares up at you from your bathroom scale, is the most important measure of your health.” He also has this weird thing, he tells NPR, “The weight you should aim for is the weight you were at when you were 20.” He says, “For most people our ideal weight, if we weren't seriously overweight, is what we weighed when we were 20.” It's like you should aim for what you weighed when you were 20. Unless you were fat, in which case it should be lower, presumably.
Aubrey: Right. I was going to say if his thing is like aim for the way you were when you were 20. Done-- [crosstalk]
Mike: I know. [crosstalk] [laughs]
Aubrey: I win.
Mike: Owned, Walter.
Aubrey: Same size as when I graduated from high school, not quite, but close. It sounds like he's a thoughtful researcher in a lot of ways and when it comes to fat people, his brain goes into the mode of, “I've already decided what I think of fat people.”
Mike: Exactly. We don't really know this story from Walter’s side. But from Katherine's side, after her study comes out in 2005, she starts getting calls from journalists who are, “I'm calling to write about the criticism of your work.” And she's like, “What criticism?” They're like, “Well, I got a call from this guy, Walter Willett, at Harvard and he says you published the study that's methodologically flawed.” At one point he calls her research, naive, deeply flawed, and seriously misleading. She's like, “What?”
Aubrey: Yeah. Which is like, that's mean. It feels a way that professional men talk to professional women to dismiss them.
Aubrey: Oh, that's naive.
Mike: I'm going to send you a little excerpt from the article that Katherine Flegal writes about this in this summer, summer of 2021.
Aubrey: Okay, great. “Almost as soon as our article appeared, symposium was scheduled at Harvard for the express purpose of criticizing our article. The lineup consisted of a small number of vocal critics, mostly from Harvard itself, all attacking our work and asserting that their previous research somehow showed that our estimates should have been higher. Although their previous research had not even addressed the topic of estimating numbers of deaths. The presentations at the symposium did not mention the multiple errors in the 2004 article. One speaker described us as having no biomedical background, even though the four authors of our article were well published senior scientists, all with doctoral degrees in nutrition or statistics, and one with a medical degree from Harvard Medical School.” [laughs] Jesus Christ.
“Seeking to maximize media coverage, the organizers arranged for the entire symposium to be webcast live and encouraged reporters to view and report on it.” What I am learning from this quote is that all these well published senior scientists are up on their high horses with their longer life expectancy and their doctoral degrees.
Mike: 10% longer, man.
Mike: [crosstalk] -Master's degree, these sickly people with master's degrees.
Mike: One of the things she mentions in this paper is that she was invited to attend the symposium but was not invited to speak.
Aubrey: That is such an aggressive move.
Mike: It's such an aggressive move. I also think on some level like holding a symposium to criticize a piece of work that you don't like, I honestly think some of this is fine, there are elements of this that is okay. But what she finds over and over again is the actual rhetoric that they are putting out, and that Walter Willett is putting out is this idea that the data is fundamentally flawed, and the methods are fundamentally flawed. It's not like, “Well, she made these choices, and we would make other choices, and these are why we would make these other choices.” It's all this weird, bad faith stuff.
Aubrey: It also feels, I'm not talking about this guy in particular, but often in the minds of people with deep seated anti-fat bias, any acknowledgement that fatness might not be as horrifically unhealthy as we have been led to believe translates to, then people will think it's okay to be fat, then people will intentionally get fat or let themselves get fatter. Then we'll be overrun with fat people which is like a nightmare for them.
Mike: Exactly. He constantly compares her work to the previous paper that found 365,000 deaths, but he doesn't mention the previous study had been corrected and then it has errors in it. He seemed to talk about it as this weird Kathy Flegal joint where like, she went out of her way to publish this like strangely ideological research. When she's like, “I work at the CDC.” After she got her data, she spent four months with the higher ups checking her data and stress testing it.
Aubrey: It feels very much some interloper just shows up and figures out, but it's probably not going to play great for him to take aim at the CDC, which is where this research originates. He instead switches to like an ad hominem approach and it's like, “It's about this woman.”
Mike: It's also so funny that to people outside of this world, he starts telling them random reporters for national publications, he's like, “The real problem with Katherine Flegal’s work is that the BMI is problematic.”
Aubrey: Oh, fuck off.
Mike: Of course, Katherine Flegal is like, the other study also used BMI. You have shown no interest in your entire career in the ways in which the BMI is problematic. This is not work you have done, you have not written about this, you haven't rejected other studies that use BMI, because the entire fucking field uses BMI. I'm the problem for using BMI and you think we should use this other estimate that also use the BMI?
Aubrey: Right. It feels a little bit the research equivalent of Stockholm syndrome with the BMI, which is terrible. And it's an open secret that it's terrible for a bunch of reasons. But also, now in order to make research that can be in conversation with other research, it is the way that researchers talk about size and health. It's the measure that people use, so you can decide to opt out of BMI, but then you're also deciding to opt out of your research being considered in concert with other more damaging research.
Mike: Exactly. This goes on for years. Blog posts start showing up on the Harvard website that say that she's been demoted from the CDC and her paper was retracted. And she's like, “What? I won an award. I got an award for this work.”
Aubrey: [laughs] “Everything's fine. I go to work here every day and people still like me and work with me. What are you talking about?”
Mike: Exactly. There's no evidence whatsoever that Walter had anything to do with this, but like someone updates the fucking Wikipedia article for obesity-
Aubrey: Jesus Christ.
Mike: -included her article and then someone said that it had been discredited.
Aubrey: What are you talking about?
Mike: They're just like this weird shadow campaign to make it seem as if she's some like rogue statistician. She's looking around and she's, “No, everyone thinks this is fine.”
Aubrey: I get so exhausted by this as a fat person, as a woman definitely, and as a person who cares about like having conversations in good faith.
Aubrey: It's such a fucking soap opera.
Mike: It's weird, hey.
Aubrey: You have all this like garbage shit to deal with at your job and you've got a co-worker who's like totally unreasonable and weird, and you can't stand to be around them. So do people at the CDC. Oh, got it. The thing that I have been taught to trust uncritically is from deeply, deeply, deeply human sources and that feels the headline of this story to me.
Mike: My headline for this is that Academia is basically the Big Brother house. These little fights going on. It just sucks in there.
Aubrey: [laughs] It's the Big Brother house but people are constantly running campaigns to get people kicked out of the house, but no one ever actually gets kicked out of the house.
Mike: Fast forward to 2013, partly in response to the criticisms of her 2005 article, Flegal starts working on a much bigger meta-analysis. Originally, she just had these two datasets from American data. But what she does is she looks for all other datasets. There're hundreds of studies going on about obesity and health at any given time. It's kind of absurd. You find these random Norwegian cohort studies and the South Korean nurse collaboration or whatever.
Aubrey: India, Australia, all around the world.
Mike: Exactly. This is a question that the entire field of science wants to answer. Katherine Flegal does like a pretty normal meta-analysis where she looks at every single study that's been published on this and she publishes a meta-analysis that includes 97 studies and 2.9 million people. She finds the same thing. Again, we have this spike of mortality for the thinnest people, and then you have a reduction in mortality for the overweight people, and then it's higher for fat people. I interviewed Katherine Flegal for this. One of the things that she noticed is that oftentimes, in these studies felt categorize people as like normal, overweight, obese. But as we've talked about on the show many times, there's actually a huge gradation within fat people. Like you're talking about people that are like 210 pounds and you're talking about people that are like 600 pounds.
Aubrey: That's a huge category.
Mike: And so oftentimes what you find in these studies is they'll say, “Overweight people are fine, but obese people, that's where all the risk is.” But then what Katherine noticed is once you start digging into their data, if you break up the fat people into, they call it again these names, they call it Class 1, Class 2, and Class 3, obesity. The lowest class of obesity, the thinnest fat people oftentimes also don't really have any health risks. For her previous study, she found that if you're 5’8” up to 185 pounds, you don't really have any health risk. In this study, which is even bigger and has more data, you can go up to 210 pounds and still not really have any elevated health risk.
Aubrey: This is where it feels worthwhile to insert that until the late 90s people who are now in Class 1 obesity category were previously in overweight categories and people who are now in overweight categories used to be in “normal weight” categories.
Mike: Oh, it's so fake dude. It's so fake.
Aubrey: It's so fucking fake.
Mike: Also, one of the things that is amazing, because I've read a bunch of these random ass studies for this too. One of the things that's incredible is they’ll mention almost like offhand. They’ll be like, “Oh, yeah, BMI for black people just doesn't work.” Some of them will be like up to like BMI of 35. You can weigh 280 pounds if you're black and not have any of these mortality statistics, but some of them have also found it like it just doesn't fucking matter for black people at all. And it's again treated as this weird footnote.
Aubrey: Oh, it's a paradox.
Mike: No reason to dwell on it. No reason to put it in the abstract. No reason to write an open letter or anything.
Aubrey: Anyway, back to the main event. White people. [laughs] Jesus fucking Christ. This is the fucking chickens coming home to roost when you made a body measurement/eventually moral assessment tool that was only built for white people.
Mike: Basically, this massive meta-analysis finds the same thing that her previous study found and that lots of other studies around the world have found this basic mechanism. Again, Walter Willett goes on the attack. He shows up on NPR and says, “This study is a pile of rubbish and no one should waste their time reading it.”
Aubrey: Wait, is that a quote?
Mike: Oh, yeah.
Aubrey: Oh, Jesus Christ.
Mike: Also tells, I believe the Atlantic, he's, “Kathy Flegal just doesn't get it.” And then Katherine's, “I go by Katherine.”
Mike: Let's just keep it Katherine, Walter.
Aubrey: That's as close as you'll get in academic research world to get my name out of your mouth.
Aubrey: Fully, like smackdown. It's great.
Mike: Speaking of unfair criticism, I'm going to be very unfair to Walter right now because he calls all these journalists and inserts himself in all of these publications about this controversy, there're quotes from him everywhere. I made like this little medley of all of the inappropriate shit that he says about Katherine in this period. I'm going to send it to you to read.
Aubrey: “When Willett sees the CDC study on obesity, his mind flashes to the picture of what he is sure this confusion will lead to. Patients packing on more weight while their doctors become less willing to broach the subject. People will get fatter, die sooner, and all the medical bills could cripple the healthcare system. Willett feels he has no choice but to go on the attack.”
Mike: No choice.
Aubrey: “It's important to push back strongly against the promotion of ideas and analyses that are based on faulty data, he says. Willett claims that Flegal clearly has a point of view on this issue. After all, she published a paper in 2005 that reached the same conclusion about the protective powers of a few extra pounds.” “The Flegal paper was so flawed, so misleading and so confusing to so many people, we thought it really would be important to dig down more deeply, Willett says. Studies such as Flegal’s are dangerous, Willett says, because they could confuse the public and doctors, and undermine public policies to curb rising obesity rates. According to Willett, the papers Flegal published were woefully misleading and undermined dietary guidelines that had been in place for several decades. Worse, he says, these findings can be hijacked by powerful special interest groups such as the soft drink and food lobbies to influence policymakers.”
“it's basically giving a green light to gaining weight and becoming overweight. We're talking about millions of lives lost every year due to obesity. It's a death spiral as this gets normalized as we look around, and everyone's overweight.”
Mike: So other than agreeing wholeheartedly what do you think?
Aubrey: Here's what I think about this. This is genuinely the shit that trolls say online all the fucking time.
Mike: It's wild. I know.
Aubrey: This is the shit. Actually like-- I genuinely don't even know where to fucking start with this. Like, “Oh no, this would undermine public policies to curb rising obesity rates,” which don't fucking work, which we’ve been doing for 20 years and have produced nothing but continually rising obesity rates. Like, “Oh, no, they go against dietary guidelines,” which change every 5 to 10 fucking years because we know very little about nutrition all told.
Mike: Won't someone think of the dietary guidelines?
Mike: Everyone, the beloved dietary guidelines and all Americans know and love and never change. Yes.
Aubrey: I can't jump inside his head. I don't know what he's thinking. What this communicates to me as a fat person and what I hear with this stuff is the ultimate terrible thing that will happen as a result of this, is that there will be slightly more people who look a little bit more like me.
Mike: I know. I also think an important thing that he says here--, is that he says, all this is going to undermine public health. And also, it's going to be taken up by powerful lobbies of like the soft drink makers and the fast-food companies. On some level, he's actually right. There are really gross corporate lobbying firms, that these fake grassroots companies that pretend to be grassroots NGOs, that say the same shit that we do. I sort of get that, yeah, there's some really gross forces aligned with what we are saying on the show, that is worth acknowledging. But also, his argument is aligned with pharmaceutical companies and the weight loss industry. You're not like the lone David standing up to like the Goliath of McDonald's. It's like you're sitting there with Novo Nordisk, dude.
Aubrey: Yeah, totally. Well, and also listen, corporations are going to use whatever the fuck is in their reach to prove their point, and that can't and shouldn't drive what research tells us. His argument, I would say is even more dystopian, which is we shouldn't research anything that corporations could then turn around and use to defend their own self-interest in their own bottom line. That's also not good. That's also corporations [crosstalk] an undue influence on science and research that we shouldn't be encouraging, dude. It just feels not only half baked, but it's leading him in unintentionally a more sinister direction.
Mike: Also, when I talk to Katherine, I think this was what really bothered her is that he's basically accusing her of having ideological motives with no evidence. There's one report of someone who was in a class of his and he said that she holds these views, she published these studies because she's a little bit plump herself.
Aubrey: Oh, get fucked.
Mike: Exactly. Look, this is a person on Twitter, this has not been confirmed, I want to be clear about the source of this information. But what bothers me is, even if that isn't true, what he's accusing her of is basically being an ideologue. She wants a policy outcome, she wants doctors to not talk to their patients, and he's skipping straight from the data to the implications of the data and accusing her of trying to bring about some sort of policy outcome. Katherine Flegal, I don't, I don't know much about her. She's actually kept her personal life completely out of the public sphere, which seems totally fine to me. But even in our phone call, she would correct me. If I was, “Yeah, I feel uncomfortable with doctors talking to patients about their weight.” She'd be like, “Well, I don't know about that. My study is about mortality rates. All I'm talking about is mortality rates. I don't really know what the implication of that is. I don't know what the policy should be.” She's always been somebody that's extremely temperate about everything she says. I've seen other interviews with her, you cannot get her to go beyond the data.
And then we have Walter Willett who's written four diet books. He has told reporters from every outlet in America that he thinks that it is dangerous to be fat and he thinks that it is irresponsible to publish scientific research that even hints at the idea that it might not be as bad to be fat as he thinks. And it's like who's acting ideological here?
Aubrey: This is also such like, every bad faith dude who I've ever worked with who just throws his weight around. Both, this is a totally extraordinary story of science getting hijacked by weird personal interactions and personal motives. Also, it feels totally unremarkable and common place. All of us, especially any of us who are not white dudes know this fucking dude.
Mike: Dude, I know. I love that it's like this is an outrage and also Wednesday.
Aubrey: [laughs] Also staff meeting. It's so remarkable and it's so not all at once. For all of my close friends and family, I can name you three of these dudes in their lives.
Mike: Yeah, I have known those dudes and I have also been that dude sometimes. [crosstalk]
Aubrey: Oh, Michael, the bravery.
Mike: Congratulate me. Congratulate me for admitting it. That’s what I want. [laughs]
Aubrey: I'm going to mail you one cookie.
Mike: Thank you. [crosstalk]
Mike: That's all I want. I don't have to actually fix my behavior as long as I acknowledge it, Aubrey. That’s very good.
Mike: Okay. Are you ready for the methodology queen section of this episode?
Aubrey: I've never been readier, Mike.
Mike: I've been saving this because a lot of the arguments that Walter makes against Katherine are technical, methodological things about how she has designed this study. I want to take them seriously. What he says in his article that he eventually publishes like responding to her study, is he says, “We believe her study is flawed. Their normal weight group contains persons who are lean and active, heavy smokers, frail and elderly and seriously ill with weight loss due to their disease.” So, he's making a specific point about her sampling. He also says, “As well as Asian populations, historically undernourished and burdened by infectious diseases.”
Aubrey: What the fuck.
Mike: Because I think she included some datasets from like South Korea or Japan.
Aubrey: What are you doing, Sir?
Mike: Walter. We're talking about human biology, Walter, and it's a normal thing to include studies from other countries when you're doing that--[crosstalk]
Aubrey: Also, that he was like, my take doesn't seem garbage enough.
Mike: Put some sprinkles on that, that has no sprinkles.
Aubrey: Burdened by undernourishment like, what the fuck, man?
Mike: So, he has a couple-- There's a lot we have to unpack here. The first argument that he levies against Katherine Flegal’s work is the problem of smoking. This is a real problem in these studies that, if you leave the smokers in, it ends up fucking with your mortality rates all over the place because smoking is so bad. Your statistical methods for getting rid of smoking and making everybody comparable across groups, but Walter thinks that that is not enough. What Walter points out is that in the skinny group, the reason why you have this weird spike among skinny people, like skinny people have really high mortality, the reason for that is because there's just like way more smokers in that group. But because smoking makes you skinny. They're not at higher risk, because they're thin, they're at higher risk because they're smokers. So, you have to remove all the smokers and then you'll get cleaner data.
Aubrey: Oh, Jesus.
Mike: In the studies that he does, he removes all of the current smokers and everyone who has ever smoked.
Aubrey: Great, cool. That's how human health works. You could just remove an entire category. I don't know, man.
Mike: A couple problems. First of all, current and former smokers is 40% of the population.
Mike: You're removing 40% of people from your analysis.
Aubrey: Yeah. They don't count.
Mike: There's also this huge problem with the category of former smokers because my grandma is a former smoker. She smoked for two years, when she was I think in her 30s, and now she's 97. But also there's also former smokers, they smoked like a pack a day for 50 years. So, it's the group of former smokers it's not clear what effect that has having on their health or their weight, but you're just removing all of them as if it's so contaminated that you can't look at them at all.
Aubrey: Also, as you have noted that's basically disproportionately removing poor people. It's disproportionately removing like a bunch of marginalized communities. And again, feels like a likely return to centering the bodies of middle-class white people. If we're like getting down to it.
Mike: Well, this is the problem, is that what you end up doing with removing all the smokers is you say that you're removing the effect of smoking. You want cleaner data, but what your actual doing is you're removing a bunch of poor, uninsured, unhealthy, thin people because smokers are disproportionately thin and you're leaving in all the fat people that have those bad health outcomes. You're just removing all the sick thin people and leaving the sick fat people.
Aubrey: It's a-- Oh, God. I don't even- I'm so fucking tired. [chuckles] I was about to say something about how, “Yeah, heaven forbid, we have actionable public health research that works for people who live at or below the poverty line.” But then I was just, I'm fucking tired. It's all such a racket.
Mike: I know.
Aubrey: Great. So, you're reverse engineering everything, so we're just researching you. And then all of our public health mandates just come from people who live the kind of life that you live, and they keep fucking only working for people who already have a lot of wealth and privilege, then fucking what? Ugh.
Mike: Yeah. The second thing that he says is contaminating her work, is that she's not removing sick people. The idea basically is that the reason why you have these higher death rates among super skinny people isn't because they're super skinny people that post photos of themselves in bikinis. They're old people who are wasting away from some sort of preexisting disease. My grandfather died of Parkinson's. In his last two, three years of life, yeah, I think he weighed like 85 pounds when he died. In the data, he would count as a death among someone with a BMI of something like 17 or something that has nothing to do with his weight. It has to do with the fact that he has this preexisting illness that first made him thin and then killed him. The spike in mortality among thin people is because you're packing in all these people that have all kinds of diseases, like various cancers, leukemia. If you're in the late stages of a disease, you're going to have a very high mortality rate and you're going to be very thin. And that also affects the normal weight category and even that slightly higher weights, you still have all these people that basically have like wasting away due to disease.
Aubrey: That's what I was going to say is, couldn't you say the same thing about someone my size, “wasting away,” could mean a loss of 100 pounds for me. That would be like dramatic weight loss, I would still be in the “obese category.”
Mike: Well, this is the whole problem. I think it's, it's so interesting once you start talking to people about the higher rates of mortality among thin people. Thin people are very likely to die according to these studies and then you watch people's minds go to, like, “Well, that's not because they're thin. It's probably because they have an illness, maybe they have a really severe eating disorder or something like that, you have all these conditions that make you thin and then kill you.” And it's like, “Wait until I tell you about fat people.” There're also medical conditions that make you fat.
Mike: Do you how many medications caused people to gain weight? I think birth control pills, it's like, typically, 15 pounds. There're mental illness medications that cause you to gain like 50 pounds. Oftentimes, those people have higher mortality rates too. So, it's the same thing is happening on the other end of the scale.
Aubrey: There are also health conditions like lipedema, which is swelling and accumulation of fat in specific parts of bodies. If we're cutting people out and going, “Okay, it doesn't apply to this person. It doesn't apply to this kind of person. It doesn't apply to this health condition.” It seems fully fucking bananas to do research on fat mortality and not account for things like polycystic ovarian syndrome, not account for things like eating disorders at any level.
Mike: Exactly. This is so fascinating to watch people explain away the higher mortality rates among thin people, “Well, it's complicated.”
Aubrey: But it's not for fat people.
Mike: Yeah. It's like okay obviously every fat person needs to lose weight because they're at like a 40% higher mortality risk, but why don't think people need to gain weight? It's like, “Oh, well, because it's complicated.” Well, it's the same data. It's literally the same table of the same study is saying that, these two groups have elevated mortality and you're prescribing a change in weight for one of those groups and not for the other group. That, to me is so revealing. It's like, “Oh, the thin people, this is a real mystery that we need to get to the heart of. “Okay, it's also a mystery with the fat people too. Guess what?
Aubrey: Even knowing that and even noticing this pattern so frequently, so commonly that people will bend over backwards to talk about why being thin is always healthier than being fat and being fat is always less healthy than being thin. You're just like, “Well, there's your bias.” And that still doesn't actually change anything in the mindset [crosstalk] of the person who's doing it. So, it's like really fucking frustrating as a fat person to see and hear these conversations happening all the time and see and hear people just showing their entire ass.
Mike: Dude, yeah, it like look we don't we don't want to strip thin people of all of their humanity. Let's figure this out before we prescribe anything, wait a minute.
Aubrey: Hey, thin people are more than a number, dude. Yeah, fucking [crosstalk] so are fat people. What the fuck?
Mike: Walter in his studies recommends removing everybody who dies within the first five years after their height and weight are taken.
Mike: He also says that after people are diagnosed with an illness, they “might become motivated for the first time to lose weight.”
Mike: Finally, a reason to lose weight.
Aubrey: Oh, good. What a good motivation is your mortality. What the fuck, man?
Mike: It's worth noting. There's no actual evidence for anything that he is saying. So, Katherine Flegal writes a very salty methodology paper about this. First of all, the number of people who are wasting away, like my grandfather with Parkinson's is actually pretty small, but people in the late stages of a disease and also those people are not very likely to answer a survey for a longevity study. They're not really contaminating your data all that much. And then this thing of removing everyone who dies in the first five years, you can actually check who are you removing and when you remove people, you're mostly removing fat people. Walter is saying that you have to do this to remove all these like sick, thin people. But then you actually end up removing a bunch of fat people, and of course, Katherine runs the numbers on a bunch of these studies. And it's like when you do this, you just raise the mortality rates for fat people.
Aubrey: Intentionally or not it's juking the stats basically.
Mike: Exactly. He talks about how you have to remove everybody with these pre-existing conditions because they might be losing weight and then eventually died due to those conditions. But there's just as many conditions where people gain weight after diagnosis. It's very typical for people to gain weight after they're diagnosed with diabetes because you start taking insulin and it spikes your appetite. There's a lot of other conditions that you gain weight once you're diagnosed because you get on medication and you start getting better. So, this idea that we have to exclude everybody who has a medical diagnosis because they're becoming thinner, it just isn't true.
Aubrey: You start winnowing out like, okay, we can't count the smokers, and then we can't count people who were previously smokers, and then we can't count people who've had cancer or Parkinson's, and then also now we can't count people who have mental illnesses and have been treated for those, but we can include the people who haven't been treated for [crosstalk] what the fuck is this weird ass patchwork that we're coming up with here?
Mike: Exactly and also what this is like after you do all these exclusions, you're excluding everybody with a preexisting condition, everybody who's ever smoked, and everybody who dies within the first five years, Katherine finds a bunch of articles that were written by Walter and his colleagues, where they're removing 90% of the deaths. 90% of the data is gone.
Aubrey: Get fucked.
Mike: The central gaslightiness of these statistical methods is that they are doing this to remove bias officially. They're like, “Well, Katherine Flegal’s numbers are biased because she left all these people in.” She's like, “Punk, you're removing 90% of the people and then you're going to tell me that it's less biased. Does this look like the US population at all, people who've never smoked, people with no preexisting conditions?”
Aubrey: Again, this is a place where it would be helpful to start the conversation, not from a place of is research biased or is it not? But where does bias lie in all research that we have?
Mike: Exactly. Among the population, around 40% of people die to something related to cardiovascular disease, like 40% of deaths in the US. But then when she looks at these samples that they're using, only 20% of the deaths are due to cardiovascular disease. This isn't a normal pattern.
Aubrey: Part of the reason why it's so hard to get to this fucking number is something that it feels none of the data is really engaging with. It turns out fat people have other health conditions and so do thin people than just the size of their fucking bodies. There's lots and lots of factors that impact people's health that are beyond this bizarre world that so much of the research wants to imagine, which is just a bunch of fat people started out as thin people and then just decided to keep eating and we're just going to measure the impact of that on their health. The number of assumptions built into that are astonishing.
Mike: This gets us to the final chapter of the story, which is basically none of this shit matters. I'm just going to go ahead and undermine everything we've already talked about.
Mike: It's now 2016, Katherine ends up resigning from the CDC. She's now at Stanford. Walter, meanwhile, has basically put together this entire consortium of, I think, it's 500 researchers or something like that. This big global BMI collaboration, basically, just to debunk Katherine's work. He publishes in 2016, this massive study that he says is to settle the debate. Her meta-analysis had 3 million people in it. His meta-analysis has 10 million people in it. It's like, “Alright, Katherine, this is it. The final word on obesity and health.” And they published the study and wouldn't you know it, normal weight people have the lowest mortality and then overweight people have more. And then obese people have like even more. “Sorry, Katherine. That's just the science.”
Aubrey: I do like the idea that the dude who started this whole “weird debate” that really just seems an attempt to torpedo this lady's credibility is like, “Guys, I got it. I'm going to settle the debate that I started.”
Mike: I also love that in this study, even all of the manipulations that will get into, thin people are still more likely to die. [chuckles] He wasn't able to get rid of them.
Aubrey: There it is.
Mike: The funniest fucking thing about this is that he's Captain Methodology. Like, “I am so disappointed with Katherine's methods.” This study is fucking garbage.
Mike: Katherine Flegal writes a series of responses that are some of those scathing, like in academic language, but very scathing language about how bad the study is. First of all, his whole thing is, of course, like he wants to remove everyone with a preexisting illness, everyone who's ever smoked, etc. The problem is among these studies that he's looking at, there's 239 studies that they're looking at, only 28 of them even have data on people with preexisting diseases. He's like, “How dare Katherine Flegal not remove these people?” And she's like, only a tiny bit of your data allows you to remove those people, so functionally you're leaving them in two. My favorite shit is that in all of their analyses of North America, it's a global study, 94% of the deaths came from studies with self-reported weight--[crosstalk]
Mike: The other thing I got totally obsessed with is that in the study, Walter is cutting out everybody who dies in the first five years and he says that you have to do this to make your data clean, and anybody who doesn't do this is publishing flawed, naive, misleading data whatever. The question I kept coming back to is like, “Well, wait a minute, why five years? Why not four years? Why not two years?” When Katherine looks into this, Walter Willett himself has published studies that cut out everybody who died in the first four years. A lot of his coauthors on the same study have published data where they cut out people who die in the first two years. It's existentially important to do this because it totally contaminates your data, but you yourself are not doing it consistently. It's weird to me that we're all supposed to see it as some sort of coincidence that he happens to choose the methodologies that produce the highest mortality rates for fat people. We're all supposed to look at this and be like, “Oh, well, all he's doing is what he considers in a content neutral way to be the best methodology for these studies. And, ah, would you look at that this aligns with exactly the policy preferences that he has been telling NPR reporters and everybody else who will listen in public.” He thinks that it is dangerous for you to be fat, he thinks that you should weigh what you weighed when you were 20, and he happens to believe total coincidence that the methodologies that produce that result are the right methodologies.
Aubrey: It just all reads to me as people grasping at straws to justify what they already believe. There's a little bit of an imperfect parallel, but a parallel to journalism and the idea of objectivity in journalism. Scientifically, we know that objectivity doesn't actually exist. That all of us are influenced by cultural biases all of the time, implicit or explicit. What would it look like to build journalism or build research around acknowledging those biases and working to counterbalance them rather than insisting that they don't exist and still doing what you were going to do anyway.
Mike: This is the whole thing. This is my grand conclusion what I want to end with. It's important to break this whole dilemma into two separate parts. For the vast majority of people who are in either the overweight category or Class 1 obesity, low grade fat people that's the majority of the people we're really talking about in America. The relative risk mortality ratios, they're so fucking small. If you even in like the Walter Willett, like pee hacked within an inch of its life study, it's like 40% higher for like grade one obesity. Again, unmarried people have a 230% increased mortality rate.
Aubrey: Guys, I'm going to die because I'm single not because I'm fat. [laughs]
Mike: This is the thing, it's like in these fake, stupid categories, is overweight and Class 1 obesity, the mortality risk rates are so weird, and tiny and conditional on these weird statistical methods at those weights, that I honestly just think that it's bullshit to tell somebody in those categories that they must lose weight. The data does not support that, I think straightforwardly. And then there are these categories of much fatter people. Once you get into BMIs above 35 or 40, it's somewhere between 2% and 5% of Americans. Very consistent correlations that those people have very elevated mortality rates, they have much higher rates of heart disease, I'm not going to deny that those correlations are extremely consistent. But then the question with much fatter people is, first of all, what is causing them? Second of all, what do we do about it?
Aubrey: Yes, it's a small number of people. It's me, I'm in that category. Hi, everybody, I'm in that category and that 2% to 5% of people are people who are already facing untold levels of stigma. We are being encouraged at every turn to treat that group of people like shit. Bad faith actors start to fucking activate and form whatever they're like, Voltron, shitty, anti-fat shit. This is already a group of people who are getting shit on left, right and center.
Mike: Exactly. If we go to those people, when you look at those statistics, it's dire. They're half as likely to be college graduates, one quarter of them are earning less than $20,000 per year, they're twice as likely to be on Medicaid, the group with the highest prevalence of grade three obesity is black women who didn't complete high school.
Aubrey: Yeah, there it is.
Mike: Is this a group that we're confident in saying? if the weight that's doing this and what they need is to lose weight.
Aubrey: Yeah, is that the biggest need that we've identified here? Also, have we listened to poor fat black women about what they want and need?
Aubrey: -instead we're focused on chiding fat people for what we assume their behaviors are.
Mike: There's all kinds of studies on, fat people do not get Pap smears, fat people do not get prostate cancer checks. If you want to say that it's the adipose tissue that is causing those health consequences, you know what? Fine. I'm probably not going to talk you out of that opinion. But it's like what can we do? What are the steps that we can take for that group that will actually make a difference? Because telling them to lose weight, we know that it doesn't work. Medical institutions define successful weight loss as losing 10% of your body weight. If you're 300 pounds, you're going to be a 270-pound person. That's the best we can deliver and not even very reliably, but there are some programs that have been shown to deliver that for some number of people, great. We now have a 270-pound person, what does that person need?
Aubrey: Right. The idea that any of this data doesn't account for medical bias and the ways in which doctors will diagnose illnesses differently, the ways in which doctors will, and healthcare providers of all stripes will have shorter visits with fat people. They'll order fewer tests. They'll consider fewer options. And then fat people, understandably, will postpone healthcare as long as they possibly can. I have a family friend who was put on prednisone by her doctor and put on weight because that's what happens when you're on prednisone. This is one of many medications where this happens and is now having significant, significant cardiovascular issues and her doctor is saying, “Well, it's because you didn't lose weight, and you need to lose weight.” She's like, “I need to go into the hospital.” These are very clear-cut cases of fat people clearly not getting the care that thin people are getting. It just feels utterly bananas that we have a cultural conversation that is dominated by thin people, and thin people's imagining of fat people's health and not the extremely overwhelming, very clear experiences of fat people on this front.
Mike: One thing is I found in one of the older papers, one of the few papers that actually investigated the causes of death among fat people, like cancer deaths are much higher among fat people. This is a pretty well-established thing. But they noticed that one of the reasons for that was that fat people couldn't fit into the machines that they needed. Also, a really interesting one was they mentioned that like fat people were much more likely to get gallstones, it's some sort of side effect of like what you're eating, but when you look into gallstones, it's also a side effect of dieting. But if you stop, especially fat consumption, but calorie consumption, your liver just goes nuts. So, 30% of people who get gastric bypass surgery and stop eating very quickly, they get gallstones 30%. It's another one of those things that is like, it's seen as like well fat people are at higher risk of gallstones and okay, but is it the fat doing that? Is it their diet or is it dieting? Those are actually like very different phenomena as a society that we would need to look into.
Aubrey: Quite a bit of the things that we think of as being the cost of being fat or actually the costs of weight cycling.
Mike: Oh my God.
Aubrey: Guess who's under the greatest pressure to diet all the fucking time? Surprise, it's fat people. Again, there are so many confounding factors and the fact that we spend zero time talking about any of them, feels like a real tell.
Mike: Wait, can I read you something?
Mike: Okay. I do think that the effect of dieting and people basically being in a starvation state for potentially years is vastly under covered, but the studies are trash.
Aubrey: Oh, really?
Mike: Oh my God. A lot of them are on fucking rats and they do show that like raising and lowering their rats weight is really bad for them. It's fine, but also rat studies. A lot of them are just slicing and dicing the same data. And people aren't gathering weight cycling data. These big cohort studies, one of the huge weaknesses of them is you're relying on what were they asking people in the 1990s. You can't go back and ask people the same questions. So, they're using the data that they have. I found a study on weight cycling, a study that shows that weight cycling is bad, but look at this fucking methodology. So, they're looking only at men of course because these cohorts are terrible.
Aubrey: Strong start.
Mike: Exactly. It says, “At the time of their first examination, these men were asked to recall their weights at age 20, 25, 30, 35.”
Mike: I know [crosstalk] you would love this. “Weight cycling was defined as a gain of 10% of body weight in one five-year interval and a loss of 10% in another five-year interval.”
Mike: That's not how weight cycling works. My mom weight cycled my entire fucking upbringing. It was not on five-year cycles, dude. It was on three months, one year.
Aubrey: Your mom and many, many, many moms. Oh, the moms.
Mike: This is what's so fascinating to me is there's so little interest figuring out any explanation for these health conditions other than obesity.
Aubrey: Yeah. There is also, I would imagine a pretty significant impact on the health of people who engage in very severe dieting, but don't meet that definition of weight cycling or that don't lose or gain weight particularly at all.
Mike: Exactly. That's the thing. And we've talked on the show about, people can be 250 pounds and eating so little that they're not getting their period. There's lots of people that are at some version of that at some level of a starvation state in their body and just maintaining that for years. They wouldn't show up in the study.
Aubrey: Say it again, there's not a single method of weight loss that is non-surgical, that meets the standards of being an evidence-based treatment. What the fuck are we doing here? If all of our research that we're conducting is reverse engineered to lead back to the same fucking mandate about weight loss, why are we doing that if we don't know how to produce weight loss? And frankly even if we did know how to make people lose weight, it is intensely troubling that we have massive societal institutions that are all geared toward forcing people to look one way and to have one kind of body. That's fucking terrifying.
Mike: Can we end with like a little epilogue?
Aubrey: Yes, please.
Mike: In 2021, Katherine Flegal, wrote an article about all of this, that is where all of this is coming from, this chronological retelling of like, “I did this work.” And this guy, Walter Willett was a real weirdo about it. Walter has always been totally clear that he regrets nothing. When he was contacted by journalists, after Katherine wrote this essay, he said, and I quote “Her description is mostly correct and she shouldn't have been surprised. I did describe her paper as rubbish and I do stand by it.”
Aubrey: Wow. The captain's going down with the ship.
Mike: She says it really sucked the way that I treated her and I feel fine about it.
Mike: You know what? Your paper was bad.
Aubrey: Yep, she's right. I did it. I’d do it again.
Mike: I have been trying for a couple of weeks to get an interview with Walter Willett because I feel if I'm going to be mean to you on a podcast, I should give you a chance to respond. We scheduled one and then he had to cancel, something moved around. But then he said, “Look, sorry, I had to cancel our interview, but I've written a response to Katherine Flegal and here it is.” The response is called, “Evidence does not support benefit of being overweight on mortality.” So just like, right back to, she's wrong.
Aubrey: Back to square one.
Mike: He says her meta-analysis did not deal adequately with the fact that smokers have lower BMIs, but high mortality. Walter, the whole debate was about whether this was an adequate way to deal with that. That's the debate, Walter.
Aubrey: Yeah, on the one hand, I appreciate his straightforwardness of just being like, “Yeah, I fuckin did. I’d do it again, what about it?”
Mike: I did it. She sucks.
Aubrey: She sucks. She's right. I did say that she sucks. I do believe that she sucks. And on the other hand it feels so disingenuous to be actually, this debate was about this other thing, where I'm like, “No, it fucking wasn't and it's all in writing, what are you doing?”
Mike: He also says that his 2016 garbage paper firmly refuted her own work, which like, no, it's just you did it differently than she did. He also says-- this is my favorite line, he says, “These are not statistical issues, but rather the reality of human biology and require detailed analyses that could not be conducted in a meta-analysis of previously published data.” Walter, you also did a meta-analysis that was based on previously published data, you're now against meta-analyses?
Aubrey: It's real wild that there's no engagement with the substance of the critique here.
Mike: It's incredible.
Aubrey: There's no point at which he appears to feel compelled to defend his own methodology. He just goes back to, “Anyway, she sucks and I'm right. Bye,” Which I'm like, “What?”
Mike: I have drafted an email to him so many times because he emailed me this paper and I read it like, "Oh, Gog. Walter, do you not see it? You're not engaging with this debate at all? Or even acknowledging that it's a debate.
Aubrey: Right. It is, I imagine reading that email was not unlike reading the one sentence where they're like, “We just assumed every fat person died being fat.” Where you're like, “You just fucking said it and published it.” And then bunch of people were like, “This science is good.” Like, “What?” Argh.
Mike: I don't want to both sides of this and say that they're both doing the same thing, because I think Walter Willett is much worse, and what he's doing is like less methodologically defensible. But also, Katherine Flegal is probably also guided by bias in this too, the process of making science is a series of judgment calls, and there's nothing wrong with that. There is a very strong association between fat people and worse health outcomes. But I think we have been told a specific way to interpret that for most of our lives. I don't think that we've been told all of the judgment calls that made that conclusion.
Aubrey: Yes. And if you're creating all this research, if you're creating this industry around reducing the number of fat people, this is what Alicia Mundy calls Obesity Inc. You are going to be training generations of healthcare providers in reinforcing their existing cultural biases using science. It's like introducing this incredibly moralizing view of patients who have no choice, but to trust you or just not get healthcare and that's part of what's happening with fat people.
Mike: Yes, oh, yeah. Also, the whole idea of boiling somebody down to their statistical mortality risk, that's a gross thing to do, regardless-- I have had this conversation with so many people, I'm like, “Oh, yeah, you probably should just not treat people according to what you think their health risks are.” I don't go around scolding smokers. And then every once in a while, you'll get people who are like, “Well, I do scold smokers, I do yell at smokers." [laughs] Congratulations on being a weird dick. Great. Good for you.
Aubrey: Yeah. Genuinely, all of this shit about like, I'm concerned about your health, all of this shit about burdening healthcare systems, all of this stuff, to me as a fat person, reads as a fig leaf for. I want to talk about how uncomfortable I am with fat people, and how much I dislike them, and how much they gross me out, and how much I don't want to be fat, and all of these other things that are not even remotely related to the health of fat people.
Mike: Yeah. It's not like people learned about the population level hazard ratios of adipose tissue and then decided to dislike fat people, it seems extremely obvious that people disliked fat people and then went looking for the hazard ratios. They were looking for a reason.
Aubrey: It's such a challenging thing to have people doing all this shit in the name of “the science” and then when you look at “the science,” it's very human, very flawed, very unreliable, [chuckles] and very disputed.
Mike: Also, the science is pretty clear that being mean to people is bad for them.
Aubrey: It's crystal clear that being a dick to people is bad for everybody's health. So, maybe knock that shit off.
Mike: But how bad, Aubrey? I need a cohort. Find me 70,000 nurses.
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