August 9, 2022 • 53 mins
What if the dangers of being heavy have been overstated, or misrepresented? This new episode of the podcast series “Losing It” explores the relationship between health and weight, and the argument that we focus on the scale too much and not enough on healthy behaviors.
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Speaker 1 (00:05):
In two thousand five, Katherine Flegal and her colleagues did
a research study. Catherine didn't think it was going to
be controversial. Unfortunately, that was a miscalculation on my part.
It was a huge deal. Catherine was a researcher at
the Centers for Disease Control and Prevention at the time,
(00:27):
and the study she was working on looked at weight
associated deaths. It actually found something surprising, something that ran
contrary to a pretty core idea about weight. Their analysis
suggested that extra pounds might not be so bad for you.
(00:49):
When they published what they found, their study kind of
went viral. I had to get a separate phone line
just to feel the calls from reporters and criticism them
came really quickly. This one professor had begun preemptively contacting reporters.
The study had been featured in the Journal of the
(01:09):
American Medical Association, a highly respected journal that vetted the
work before publishing it. But an academic was going around
telling the press that Catherine's study was bad. So by
the time they talked to me, they had already talked
to another person who had said that my stuff was
rubbish and completely wrong and fatally flawed. And things like that,
(01:34):
And something similar happened at a scientific meeting not long
after the paper came out, and this other professor took
the stage when he wasn't supposed to be speaking and
just issue the condemnation of our article, just out of
the blue. So what was everyone so angry about. Anyway,
We were trying to estimate the proportion of this in
(01:55):
the United States that were associated with different bm I levels.
Cavin specifically for a CDC division known as the National
Center for Health Statistics. That's the agency responsible for coming
up with data to help make Americans healthier, And like
Catherine said, she was focused on figuring out how many
(02:17):
deaths in America were associated with different b m I s,
or body mass index, which is basically a mathematical formula
for estimating a person's body fat. In other words, Catherine
was investigating the link between weight and death. But these
(02:39):
weren't just numbers something to stick on a website or
pamphlet somewhere and forget about a lot of things done
at the National Center for Health Statistics are supposed to
influence policy. At the time, body weight was already emerging
as public health enemy number one. The deadly impact of obesity.
(03:02):
The toll on Americans far greater than previously thought. Why
are Americans so fat? The United States is the world's
baddest developed nation, with an obesity right double of that
in many European countries. The CDC had declared obesity a
growing epidemic years earlier, and Catherine and her colleagues weren't
(03:26):
the first to look at the subject. The paper that
came out before ours estimated that obesity was about to
overtake smoking is the major cause of death in the
United States. Remember, at this point, there was also tons
of awareness that smoking is bad for you, So the
idea that being heavy could be more dangerous than smoking
(03:49):
that really sent people into a tail spin. It looked
like America had this big weight problem. But when Catherine
and her colleagues sat down to do their own analysis,
they came to a very different conclusion. Our paper didn't
suggest that the city associated deaths were anywhere. They're likely
(04:10):
to overtake smoking as a major cause of death. Using
data from what's called the National Health and Nutrition Examination Survey,
they examined the health of tens of thousands of Americans.
They also tracked how many of those participating over the
years had died. If you look at the number of
(04:31):
deaths and you adjust for all these things like age
and gender and socio economic data and so on, we
get this many more desks than would be expected, and
this many fewer deaths would be expected, making that comparison
to normal weight. They basically wanted to figure out how
many more people considered overweight or obese we're dying then
(04:53):
would have been expected if they had been at a
so called normal weight A. When they crunched the numbers,
Katherine and co. Found that obesity wasn't about to pass
smoking as a top cause of death in the US,
not even close. They also found that the number of
(05:14):
deaths connected to higher b m I s is actually
pretty low, so it was a very different result. They
find that fewer people with a b m I classified
as overweight We're dying than would have been expected at
a normal weight b m I. We didn't say that
these things are caused or were protected, or that or
(05:37):
we is protected. We just reported the numbers. Now, people
have a lot of takeaways from that, but I don't
feel responsible for all their takeaways. But to say the
least they're finding was really unexpected. After all, carrying around
extra pounds is supposed to be bad for you. That's
the whole basis for medical categories like overweight or obese.
(05:59):
This is the scientific foundation on which weight lost empires
have been built. Where did that idea come from? Anyway?
And is it even true? What Catherine and her team
found called at least some of this into question, so
other scientists freaked out. It seems like they decided the
(06:23):
only explanation was that Catherine and her team had messed
up somehow. That was easier for them to swallow than
considering the opposite, that Catherine and her team could actually
be right, that the relationship between weight and health could
be different. The funny thing is this Catherine and her
(06:48):
colleagues hadn't meant to call into question the very foundations
of weight science. We just blundered into this. I mean,
we weren't trying to cause a fire. Back to what
Catherine and her colleagues found, It wasn't that there was
no link between b m I and death exactly, but
(07:09):
that link existed among people with higher b m I
of thirty or higher, which is the cutoff for obesity,
and especially thirty five or higher, and when the researchers
added it all up, the total number of deaths tied
to these categories of overweight and obees turned out to
(07:33):
be pretty small. More people were dying in those years
from car crashes and gun violence, and more people were
definitely dying from smoking, so there was a very large difference.
Before Catherine published the research, she also looked at a
bunch of other studies. She wanted to know whether her
(07:56):
team's findings were unusual. After all, their paper contradicted what
most people think about weight and health, at least when
it comes to the category of overweight. But it turned
out that there's wasn't even the first study with findings
like these. There's a lot of other studies that have
(08:17):
shown this already, so it's not a big deal. Those
other studies had also found little risk of death associated
with having a b m I classified as overweight, But
it was Catherine's study that for some reason really struck
a nerve, and a lot of those tacks were coming
from academics at one particular institution, Harvard, especially this one
(08:42):
guy Walter Willet. At the time, Walter was the chair
of the nutrition department. After another paper, Catherine wrote, he
went around calling her work a pile of rubbish and
said people should ignore it. The prestigious journal Nature actually
(09:03):
ended up writing an editorial basically criticizing Walter's comments and
saying he was oversimplifying the science. But there was more
than just that. And then the Harvard School of Public
Health group that was mainly, although not exclusively, the antagonists here,
(09:23):
they decided to schedule a symposium at Harvard to basically
to show what was wrong with my article. That's right.
Researchers opposed Catherine's findings so fiercely that they put together
a whole event just to talk about how much they
hated it. And Catherine says that the conference organizers didn't
(09:44):
even make it possible for her and her co authors
to attend. As you can imagine, all of this was
a lot for Catherine. This is getting really stressful. I
had a very high adrenaline level, I would say, because
I was always finding the weird attacks in places that
I just would not have expected, like Wikipedia. The gist
(10:04):
of all this criticism was that there were things Katherine
and her colleagues had simply missed. They had found. The
people living in bigger bodies were dying at similar rates
to those in smaller bodies. But like I said earlier,
it was easier for prominent scientists to imagine that Katherine
and co. Were wrong, then that they're finding could be true.
(10:28):
The explanation critics landed on, according to news coverage at
the time, was that their numbers must have been off.
After all, people can be thin because they're sick with
diseases like cancer, or because they're elderly. The critics said
that these sorts of things must have thrown off the study.
(10:52):
They also said that Katherine's team didn't use enough long
term data, but Katherine says, no, that wasn't it at all.
The issue was that people had already meet up their
minds about weight and health, and Catherine was undermining those
preconceived notions. Catherine was basically an atheist, renouncing the gospel
(11:16):
about weight and health. There's this real drive to say
anything finding like that is unusual. It needs to be
explained away. We need to get rid of this. How
do we get rid of it? We've got to say, well,
maybe it's because of ages, or maybe it's because of this.
It's because of that, you know. So there's all you
have to explain away in convenient findings. Catherine says this
stuff wasn't really an issue, and in fact, she and
(11:40):
her team said right in their paper that factors like
illness and duration of follow up didn't have a big impact.
So this was all based on pretty much nothing, But
it was very influential, and this kind of stuff went
on literally for years. Disagreements like these are actually a
really key part of the scientific process. The whole point
(12:04):
is to go back and forth about findings so people
can trust that they're accurate. But the way Catherine describes it,
the criticism crossed the line. What could have been a
legitimate scientific debate evolved. Misinformation started flying, Like when one
group claimed that Catherine's findings were renounced by the CDC,
(12:29):
she says they weren't. When I asked the CDC about it,
they didn't get back to me. So there's just all this,
at least falsehoods lying around, and I didn't know what
to do about them. Some of it was just kind
of disrespectful about Catherine's skills as a scientist. The one
who was kind of insults saying that my paper was
(12:50):
my faintly flawed. That was nonsense. It was rubbish, that
we made very simple errors that were completely wrong. Harvard
didn't return a request for comment by our deadline. In
an email to me, Walter Willett said that Katherine's paper
quote was causing serious confusion among physicians and patients, with
(13:11):
potentially dangerous clinical and public health consequences. He also says
that many large analyzes have refuted the findings showing that
overweight and obesity have poor health effects. It's clear from
talking to Catherine that these criticisms rankled her because she
(13:31):
cares a lot about the science. She retired from the
CDC in and is currently a consulting professor at Stanford.
But the attacks became personal too. Lisa and Darovitch, who
was a PhD student at Harvard about a decade ago,
(13:51):
said a professor there even criticized Katherine's weight, saying that
was why her work couldn't be trust stid. I got
very stressed trying to deal with this stuff and trying
to respond to things that people were saying. This was
Catherine's scientific reputation on the line, This is her career,
(14:13):
and this loud chorus of scientific feedback is saying legal
must be wrong. Legal is wrong. Legal is wrong. She
must be wrong, or this must be wrong, or therefore
she's wrong. But what if Catherine wasn't wrong? What if
the dangers of being heavy have been overstated or misrepresented?
(14:34):
A small but vocal contingent of experts and advocates say
just that. They argue that weighing more isn't inherently bad
for you. In fact, when people say that, they are
mixing up correlation and causation, a classic scientific error. This
is obviously counter to the predominant thinking. But the idea
(14:58):
here is that we have been folk using on the
scale too much and not enough on healthy behaviors. Our
weight bias has become a major blind spot, something that
keeps us reciting the same old lines about weight and health,
even as a body of scientific evidence suggests that this
(15:19):
way of thinking is wrong. We're going to get into
that in this episode, and we're going to take a
close look at evidence behind it. I'm Bloomberg News health
reporter Emma Court and from the Prognosis podcast This is
Losing It. There's some things pretty much everyone will agree
(15:51):
is true. The earth is round, the sky is blue,
and weighing more is bad for you. That's the message
we get in a million overt and subtle ways every
single day. Just look at who gets featured on the
cover of fitness magazines. And then there's the actual messages
(16:15):
people with bigger bodies get from their doctors, from friends
and family, and even sometimes from random people on the street.
Lose weight and you'll be healthier. Tracy Man, a psychologist
who runs a health and eating lab at the University
of Minnesota, puts it really well. The air we breathe
(16:39):
is weight stigma. Treating people in bigger bodies poorly is
so common that lots of people don't even notice it
or think of it as discrimination. We've been brought up
with views that it's not okay to be obese and
that you need to be thin, and you, at least
a minimum need to be trying to be thin. Tracy
(17:02):
thinks that's why diets keep getting pushed over and over
and over again, even though they don't really work for
long term weight loss, not for most people anyway. Like
she says, even if the deck is stacked against you,
the expectation is that you should at least try to
be thin. The message is persistent. Getting thin should be
(17:25):
your goal, otherwise you're doing it wrong. The way Tracy
put it really struck me. Wait, stigma is the air
we breathe, and so is the idea that living in
a bigger body means you're unhealthy. Think about it. When
did you first hear that weighing more is bad for you?
(17:50):
And how often have you heard it since then? Every month,
every hour? Did you ever question why that's the case
or have you always just accepted it at face value?
I'm guessing that for most of us it's the latter.
I've just heard it said that that you can be
(18:11):
fat and healthy. Actually you can't think. I'm sure that
you're excess if that is unhealthy, I don't think anyone
is agons off with it. But how do we know
that being heavy is bad for you? Tracy and others say,
we actually don't. We don't know that. We know that
(18:32):
people at heavier weights can have health problems, but they
don't always, and it's not clear that weight itself is
the issue. Here's the deal. Higher B M E s
are at greater risk for a lot of different diseases,
medical conditions, and depth. It's a really long list, so
(18:56):
I'll just read it off the cdc S website. High
blood pressure, high cholesterol, type two diabetes, coronary heart disease, stroke,
gall bladder disease, ost arthritis, sleep apnian, breathing problems, many
types of cancer, mental illness like depression and anxiety. You
(19:18):
get the idea. You hear this kind of thing all
the time, like from doctors who say, all of the
chronic diseases that we deal with, high blood pressure, cardiovascular disease, diabetes,
they're all related to weight problems. The CDC also lists
some more vague sounding things as risks if you're heavier,
like low quality of life and body pain and difficulty
(19:42):
with physical functioning. You might be wondering what the connection
is between weight and all these problems, the why of
it all. Doctors and scientists are specifically concerned with extra fat,
which they say can put lots of stress on the body,
(20:04):
including pressure on bones and joints, and fat cells can
lead to inflammation, affecting things like regulation of blood sugar levels,
which can lead to diabetes. But again, the conditions I
listed earlier are risks associated with higher weights, Like the
(20:25):
doctor we just heard talking said, heart disease and diabetes
and all the rest are linked with weight or associated
with weight the reason for all that careful language. Here's
tracy again. Weight is correlated with many problems, but correlation
(20:47):
does not mean it's causing those problems. Correlation is not causation.
That's kind of a big rule in statistics. Admittedly, I
haven't been in a math class in a long time,
but I remember pretty clearly that in high school one
of our teachers actually had us banging on our desks
(21:09):
and enchanted. Correlation is not causation. Correlation is not causation. Now,
there are a lot of places where conflating correlation and
causation becomes a problem. One of the classic examples has
to do with ice cream and murder. Ice Cream sales
(21:31):
increase in the summer, and so do the number of murders. Therefore,
ice cream causes murders. Seems straightforward enough, but of course
that's wrong. Murders and ice cream consumption both go up
at the same time because of a third factor, rising temperatures.
(21:54):
When it's warm, people eat ice cream, and just generally
people are out and about more. They're doing more of
lots of kinds of activities, including apparently committing felonies. Ice
Cream may be delicious, but it is not to blame again,
Correlation is not causation, and with weight, just like with
(22:18):
ice cream and murders, there are other factors that could
help explain what's going on, things like lifestyle. More on
that in a minute. We want to understand why so
many diseases occur so we can prevent them, and many
diseases are associated with weight. Studies have also shown that
(22:44):
when people lose weight, they lower their odds of developing conditions,
including diabetes, and improve things like cholesterol levels. Evidence seems
clear right losing weight is the way to improve your health.
But the experts and advocates I spoke with for this
(23:06):
episode tell a very different story. They say that we
unfairly blame weight for really complex scientific questions and treat
dieting as a quick fix. Except it's actually not a
quick fix because, as we've learned in this podcast, losing
(23:28):
weight long term is a really challenging and almost impossible enterprise.
So what could be actually causing these diseases and other
issues if not weight? Now, this is a subject that's
really charged, so I ask you to reserve judgment. Here
(23:52):
are experts out. It turns out that there are a
lot of things that are correlated with weight, aren't so
good for you, including being sedentary. Sedentary a k a.
Not moving around a lot. This is actually a pretty
big issue, and not just for people at heavier weights.
(24:14):
Many many people live sedentary lives. We drive to work,
we sit at a computer, that kind of thing. In fact,
people in the Western world have been living like this
for hundreds of years. We talked about that in episode two,
how the Industrial Revolution shaped the conditions of modern life
(24:34):
and modern dieting and made us all a lot more
likely to just sit around on our butts all day.
At a certain point, it starts to get tough to
separate out how we live from how much we weigh.
You get into a little bit of a chicken or
egg thing. Here's Glenn Geyser, a professor of exercise physiology
(24:56):
at Arizona State University. People who are overweight or beasts
tend to be less physically active. They tend to eat
unhealthier diets. That is on average what we see. But
that doesn't mean that the weight is the problem. Means
that it's probably the lifestyle. The problem is lifestyle, not weight.
(25:18):
This is the problem that we have in America. We've
got this disconnect. We think weight is the big issue
when it's really not. It's the lifestyle that oftentimes goes without.
Of course, weight is way more complicated than just lifestyle.
Not all of it is in our hands. Your genetics,
for example, are a really important factor too, but you
(25:42):
can actually change your lifestyle. Higher weights are also connected
to other things too. Here's tracy again. It's also correlated
with poverty, and there's a ton of research showing links
between poverty and health problems. Heavier people also experienced stigma.
(26:04):
Often they're treated worse because of how they look. That
has been shown to be correlated to health problems, even
controlling for whatever the person weighs, and there's lots of
reasons for that. People in bigger bodies often go to
the doctor and just get told to lose weight, almost
as a reflex. Doctors just assumed that weight is the
(26:28):
issue and don't investigate what might actually be causing someone's
health issues. And when things like that happen, people get
sicker and they also avoid doctors. That's wait stigma in action.
Wait stigma is incredibly prevalent, not just for medical providers.
(26:50):
Doctors are the number two source of fat phobia and
wait stigma outside of family. This is Veronica Garnett. Veronica
is a dietitian and one of the leaders of a
group called the Association for Size Diversity and Health or ASDA.
And then if you're in a fat phobic we live
in a fat phobic society and world. It is stressful
(27:11):
to be treated poorly because of the way you look.
Lots of evidence has suggested that stress is not good
for people and can have all sorts of terrible effects
on their health. It starts to feel like some kind
of vicious cycle. We assume people's weight makes them unhealthy,
(27:31):
and those assumptions then harm their health. It's also stressful
to navigate a world that, just in general, was not
designed to accommodate your body. Here's Annie Jansen, another one
of asda's leaders. Annie is also a dietitian and has
a master's in public health. Fat people's health is impacted
(27:54):
by fat phobian weight stigma. Even outside of the medical realm.
Chairs are are not accessible to all people. In restaurants,
um and theaters, and other public spaces. UM people face
direct hate and comments about their bodies when they're out
in public, limiting their ability to participate in public life.
(28:17):
Doctors are people affected by bias like any other person,
and bias can also affect the scientists doing the studies.
It's easy for people to find diseases correlated to higher
weights when the research itself is biased um, and it's
easy for people to accept that and not really be
(28:37):
critical about how well done those studies are. There's one
more thing, a really important thing. As we've established by now,
people who live in bigger bodies are facing all this
pressure to diet and lose weight. Losing weight isn't usually sustainable,
though so many people gave weight back. This is known
(29:03):
as yo yo dieting, or, in more scientific terms, weight cycling.
There's actually a lot of evidence connecting it with health problems.
Weight cycling is an independent risk factor for diabetes, hypertension,
insulin resistance, and a slipidemia, which is essentially high bad
cholesterol and or good are low good cholesterol. You'll notice
(29:27):
that all of those disease listed are typically diseases associated
with higher BMI. This is again something that studies have found.
I know you're sick of me saying it, but correlation
is not causation. So how come with weight we've thrown
out this incredibly basic scientific principle. A lot of doctors
(29:50):
and scientists would say that we have it, and that
there's clear evidence extra weight harms health, evidence like the
way people's health and prooves when they lose weight. But
as I spoke with sources for this episode, I began
to wonder whether we're just more willing to let correlation
(30:11):
equal causation when it comes to weight, because we've already
convinced ourselves that being thinner is better. By the way,
not all of the findings about higher weights are bad.
When it comes to a variety of diseases like heart disease, cancer,
(30:31):
and diabetes, research has found a connection between obesity and
longer survival. In other words, it looks like when heavier
people get sick with these diseases, they actually might be
less likely to die. This is again an association correlation.
(30:55):
We can't go as far as to say that weighing
more is the reason people with these diseases survived longer,
though some scientists have said they think that could be
what's going on, and longer survival is of course a
good thing. Still, these kinds of findings don't go on
(31:18):
the CDC website under obesity. Remember that long list of
medical conditions associated with higher body weights. The government's web
designers don't like go edit the page and add an asterisk.
If they did, the website might say overweight an obesity
(31:39):
put people at higher risk for diseases like diabetes asterisk.
But people in bigger bodies who get diabetes actually live
longer than people in smaller bodies with the same disease.
Weighing more is supposed to be bad for you, and
yet in certain cases it doesn't look bad for you.
(32:02):
That's called the obesity paradox, and it does at some
levels seem pretty paradoxical. But let's become a term that's
used for just anything that shows obesity is good for
you or might not be so bad for you as
a paradox. Why is it a paradox because you don't
expect it. That was Katherine Flegal again from earlier. Everyone
(32:26):
already agrees that being heavy is bad for you. Anything
that counters the narrative, well, it must be a paradox.
Catherine's research also ran counter to the mainstream narrative, and
a lot of people went to a good deal of
trouble to discredit it and discredit her. But remember how
(32:48):
before she published, Catherine went through other scientific papers. She
actually found that a lot of articles had similar findings.
That's why she was so surprised by the reaction to
her paper. If that's the case, why did Katherine face
this big wave of criticism and bad feedback about her
(33:09):
work for years afterward. Now, when I look back, I
realized that most articles kind of like ours, would not
would not just publish the numbers they would come. They
would start with something, well, everybody, it's really bad for
you because it causes like X, y Z, And they
would have all and it costs all us money. But
even though it costs all us money, it is so
bad for you, and less found this number, but don't
(33:30):
pay any attention to it. In other words, most researchers
would open their studies with a long disclaimer saying that
extra weight really is unhealthy, even if that isn't exactly
what their research suggested. I took a look at some
of the scientific papers about the so called obesity paradox,
and a lot of those articles are kind of like
(33:52):
that too. They open with some variation of obesity is
a big, big problem, will be to be bad. Obesity
kills people. I'm paraphrasing, of course, and then the studies
go on to say that patients with diabetes who are
heavier actually die at lower rates, that when they get
(34:13):
cancer they actually survive longer. To me, this is a
story about bias, how it can affect even scientists who
are supposed to be led by just the facts and
the data. It's also a story about group think. Once
there's a narrative out there and it's firmly settled, people
(34:34):
don't want to complicate it. What if they're wrong, They
would look pretty stupid. Catherine points out another piece of
this that scientists are people too, people who have specialized
in an area and get money to study it and
whose career advancement depends on it, and like anyone else,
(34:57):
scientists have goals, power, funding status. I think it would
be career ending. Career ending. She's saying that because of
how ferociously her work was attacked. That's what happens when
you complicate the narrative about wait, or even when you
(35:18):
undermine it. It's worth pointing out that complicating the narrative
didn't end Catherine's career. Those things did get pretty unpleasant,
but Catherine's career at least was protected. We were all
senior government scientists that inn that we couldn't really be fired.
We didn't depend on grants, and we didn't need to
get tenure or anything like that. We couldn't be promoted
(35:40):
any higher. She says, it would have been a whole
different story if she was an associate professor somewhere. I
would never want any grants. That would have ruined my career.
It was only later that Catherine started thinking of this
whole dust up a little differently. It felt like her
fellow scientists had taken a side on the issue all,
almost as if it were a political campaign. I actually
(36:03):
was surprised the first of my thoughts I heard someone
mentioned the idea of sides, like I don't have a side.
This is the data we use, these are the methods
we use. It's not a side. It's not a statement
of opinion. It's not like personal opinion. It was like
Catherine's fellow scientists had decided being bigger was bad for you, period,
no nuance, no questions about it. It's been fully established.
(36:29):
Any data that contradicts it, that data can just shove
right off. So to summarize, the idea that weighing more
is bad for you is incredibly prevalent, but well, it's complicated.
In fact, there's a group of researchers and advocates who
(36:51):
argue that the dangers of being heavy have been exaggerated.
They say we've scapegoaded weight for diseases when there could
be other causes, like a lack of activity or not
eating particularly healthily. And when scientists put out research that
suggests being a little bigger isn't so bad, they face
(37:14):
these vigorous attacks from really prominent people for years. All
this brings us to the billion dollar questions can you
be healthy at higher weights? The experts we spoke with say, yeah,
you can be. Something that we actually can solve is
(37:36):
how to make people healthier. Much easier to make people
healthier than it is to make people thinner. I'd say
this all the time, and I don't know why it's
so radical a thing to say, but behaving in healthy
ways will make you healthier. It just won't necessarily make
you thinner. Healthy behaviors like exercising, eating our vegetables, getting
(38:01):
lots of sleep, and reducing stress, even if those things
don't make us lose weight, which they may not. Here's
Glenn Geeser, the Arizona State University professor again, and at
some point in our life we have to kind of
just say, look, this is my weight. This is about
it for me. I'm just gonna have to settle for this.
(38:22):
But that is not the same as saying, look, I'm unhealthy.
I'm just going to have to settle for this. Because anyone,
regardless of their weight, can improve their health with lifestyle change,
and as obvious as it sounds, people at all different
weights do all different levels of these healthy things, which
(38:42):
is part of the reason it's so wild we group
people together in these broad, undifferentiated categories. It's like telling
everyone who is at a so called normal weight, you
get a free pass vegetables. Who needs them stay at
that weight and it doesn't really matter what you do.
(39:03):
B m I stigmatizes those who get classified as overweight
or obese because of it, but so called normal weight
people are also getting led astray by b m I
because they might think they're fine and don't have to
exercise or anything, even though their lifestyle might be putting
them at risk. Everyone is getting screwed. Someone who is
(39:27):
classified as overweight or obese by the body mass indexed criteria,
but exercises a lot and has a modest, at least
a modest level of fitness. They tend to be better
in terms of overall health outcomes than thin people who
are very sedentary. So fitness matters, fatness not so much.
(39:51):
That's great news for jim rats around the world. But
here's the thing. All those classic healthy things I just
listed off earlier, lots of people aren't doing them. This
isn't me being judgmental. All that stuff is really hard
to do the way society is set up. It's hard
(40:14):
to make time to work out. It's hard to eat
better when healthier food is way more expensive and inconvenient.
It's hard to sleep more and reduce our stress when
we lead busy lives and have stressful jobs. The world
we live in is not built to encourage or support
healthy behaviors, but there are things we could do to
(40:38):
change that. First, let's talk exercise. The US government recommends
a few hours a week of moderate cardio plus at
least two days of muscle strengthening. Most adults aren't doing that,
and the government actually tracks what people eat. How it
(41:01):
compares with dietary guidelines. That score has gotten a little
better over time, but it's still not great. In Americans,
eating habits rated a fifty ninety nine out of hundred
at some schools, that's a failing grade. What it means
(41:23):
is that we're definitely not eating enough vegetables, fruit, or
dairy each day, and getting the right kinds of grains
and protein like whole grains and nuts can be a
problem too. So people aren't moving enough and they aren't
eating so great. But then let's say they go on
(41:45):
a diet. They start exercising more and eating in more
healthy ways. They're doing those quintessential healthy behaviors, and the
most common ways to lose weight are through exercise and diet.
And remember are that laundry list from earlier, of all
the health risks tied to heavier weights. Doctors and scientists
(42:08):
will tell you that the way you reduce those risks
is to lose weight. But also, the funny thing about
diets is that sometimes when people go on diets, they
actually lean into a lot of those healthy things. So
now you have to ask the question, will wait a minute,
if people are exercising and dieting, when they lose weight.
(42:30):
How do we know that it's the weight loss that
improves the health and not the exercise and the healthier eating.
Glenn says that there are studies where people with b
m I is considered overweight and obese change their diet
and exercise, but don't lose much or any weight. And
(42:52):
why do you know these folks start looking healthier by
measures like lower cholesterol. And in study of what's known
as the Dash diet, which helps people reduce high blood pressure,
researchers actually prevented participants from losing weight. They did that
(43:13):
by weighing people and adding in calories when needed, and
people's blood pressure declined. Anyway, long story short, people can
improve their health without losing weight. Tracy Man from the
University of Minnesota says it's actually easier. It's really really
(43:37):
hard to lose weight and keep it off, but eating
your vegetables and getting your steps in that's within reach. Still,
it's kind of a tough sell, right You're telling me
to get on a treadmill or whatever, and I'm not
even going to drop a pant size. We need to
(43:58):
find a way to help people stick to those health behaviors,
especially physical activity thing. Two, we've got to get rid
of weight stigma, because as long as there's weight stigma,
people are going to keep trying to diet, and people
are going to continue to make obese people uh feel
bad and suffer in various ways that are unfair and unjust.
(44:19):
Um And three, we need to find a way to
help people feel satisfied with whatever body they have once
they are behaving in healthy ways consistently. That body won't
necessarily be thinner at then as you want, but that's
your healthy body, and we've got to find a way
to be satisfied with that. Freecy's Lab at the University
(44:40):
of Minnesota is working on those right now. Adding vegetables
to your diet um and especially doing the recommended amount
of physical activity each week. Those are lifestyle changes and
people should do them. Again, doing them doesn't mean you're
gonna lose weight, Doing them doesn't mean you're going to
be thin, and but doing them does mean you will
(45:02):
improve your health. You have to measure health in a
different way now at the scale, approaching health in a
way that's way inclusive. There's actually a movement behind it
called you Guessed It Health at every size. What we're
(45:23):
trying to do currently, and the current mainstream approach to
health and weight isn't working. This is Annie again from
asda as that advocates for health at every size. What
we see in the research is that efforts to make
that people thin are failing. They fail over and over
and over again. We have decades, literal decades of research
(45:46):
and so those are not things that people can just
choose to do, like they could choose to eat more vegetables.
And so what what happens when we shift the focus
to things that people actually have control over, like what
they eat, or how they move their bodies or web
or not they smoke any Veronica and their fellow activists
are fighting for exactly that, for people to stop treating
(46:08):
weight as the equivalent of health. They say that we've
been telling people to lose weight for their health and
that's not only wrong, but it's actually causing a lot
of harm. The vast majority of doctors today are still
very fat phobic. Ultimately, we need healthcare practitioners to understand
(46:29):
what the science really does say and and right now,
the science is contrary to what the mainstream beliefs about
fatness are. And if a fat person is going to
get good care in the hands of a doctor. We
need people to also understand what the science and research
says about weight and weight loss. This is again contrary
to how society still thinks about things. Any points out
(46:51):
that just having a certain b m I, a b
m I that's considered in the obese range, is now
itself being called a disease. But the activists at ASDA
are fighting for more than that too. Veronica and Annie
argue that even the idea of health itself is broken.
(47:12):
After all, how did scientists come up with standards for health.
They did it by mostly studying white heterosexual men. We
are trying to shift the way that we talk about
health in health at every size so that we don't
continue to uphold those white centric, erocentric um standards within
(47:33):
our own movement. One way to think about this is
in terms of how much we value health as a
society and what that really means. Health is often defined
as the absence of disease right off the bat. That
leaves a lot of people out, and on top of that,
some of the sickest people in society are also the
(47:54):
most marginalized people like people of color, LGBTQ people, more people,
A fat person, uh could live this healthy, long, happy
life according to these Western Eurocentric standards of health. Right,
this is Veronica again. But let's say they don't. Let's
say a fat person does develop diabetes, then what do
(48:15):
we do? Do we not care for this person? Are
they just disposable? Um? And like a lot of times
it plays out in our medical industrial complex, like fat people, uh,
disabled people, aging and chronically ill people are just seen
as disposable. And like if we look at the pandemic
that we're living in, some people were just left to
(48:36):
die or people like, oh, well, it's only this COVID
is only affecting certain people, so like I don't have
to worry about it, and those people could just get
sick and die. But is that the type of world
we want to live in? Is that the type of
health care system like we want to uphold? Veronica says
that ASDA wants to change these things to people, no
matter what size they are or what health can soon
(49:00):
as they have or don't have, or whatever deserved care,
they deserve equitable, barrier free access to the care and
resources they need to support their well being. I wonder
like what our health care system would look like if
we actually just all acknowledge that being sick, being like,
becoming disabled, being disabled, getting old and dying is a
(49:24):
normal part of the human experience. That means getting the
message across about health and we isn't enough. Historically, the
movement has really promoted this idea that we just need
to get healthcare professionals to stop prescribing weight loss and
to stop using BMI as a measure of health and
(49:46):
kind of like we'd be good, like we'd be done.
And honestly, this promotes a very white centric view of it,
because for a fat white person, if you can eliminate
that barrier, all of the sudden, you have health care
that affirms you. But and he says that isn't the
(50:07):
case for lots of other people, including black people, trans people,
and disabled people. That's changing what their organization fights for,
things like who gets a seat at the table when
people are doing research. The way health insurance is structured
use of b M I to access health care services
(50:28):
like surgery. And now I think what we're shifting to
is really this understanding that the way that we define
health as a society, the way that we define it
when we study it in our research studies, and the
way that the health care systems engaged with people are
(50:48):
barriers on so many levels that we need to start
dismantling and reconstructing the whole thing because they were based
on one kind of person. It's not just our ideas
about weight and health are wrong, it's that they are damaging.
We can all be doing a lot more to shift
how we think about these things and to make the
(51:10):
world a better place for people in bigger bodies. As
we do that, though, we've still gotta eat. And the
thing about eating is that we've gotten pretty messed up
about it. All. This talk about what's good for you
and what's bad for you really does a number on people.
Diets put so so many rules and food, and they
(51:34):
can be incredibly hard to unlearn. If we put the
diet to rest, stop making weight loss the goal, then
what is there a way to be satisfied and healthy
in whatever body we've got With self care, self compassion,
tuning into hunger, fullness and enjoyment satisfaction, our bodies are
(51:56):
going to be what they're going to be, and it's
about learning how to be liberated from a belief that
you have to change your body in order to be acceptable.
Next week, on the final episode of Losing It, we
dive into the world of intuitive eating. The scale is
just a false idle and what we lose when we
try to lose weight? What would you spend those on?
(52:20):
What passions do you have of? What creativity would you
spend it on? What hobbies? What you know? Spending time
of loved ones? Like what would you do if you
got that time back? Getting rid of diets? Eating without
thinking about weight? Is that even possible? Losing It is
(52:41):
written and reported by me I'm a Court and edited
by Kristin B. Brown. Magnus Hendrickson is our senior producer,
Stacy Wong our associate producer, and Blake Maples is our
audio engineer. Our theme was composed and performed by Hannis
Brown thanks to Francis A. Leavi and Tim and Nette.
(53:02):
Be sure to subscribe to Prognosis if you haven't already,
and if you like our show, please leave us a
review that helps others find out about it. Thanks for listening,
See you next time.
In two thousand five, Katherine Flegal and her colleagues did
a research study. Catherine didn't think it was going to
be controversial. Unfortunately, that was a miscalculation on my part.
It was a huge deal. Catherine was a researcher at
the Centers for Disease Control and Prevention at the time,
(00:27):
and the study she was working on looked at weight
associated deaths. It actually found something surprising, something that ran
contrary to a pretty core idea about weight. Their analysis
suggested that extra pounds might not be so bad for you.
(00:49):
When they published what they found, their study kind of
went viral. I had to get a separate phone line
just to feel the calls from reporters and criticism them
came really quickly. This one professor had begun preemptively contacting reporters.
The study had been featured in the Journal of the
(01:09):
American Medical Association, a highly respected journal that vetted the
work before publishing it. But an academic was going around
telling the press that Catherine's study was bad. So by
the time they talked to me, they had already talked
to another person who had said that my stuff was
rubbish and completely wrong and fatally flawed. And things like that,
(01:34):
And something similar happened at a scientific meeting not long
after the paper came out, and this other professor took
the stage when he wasn't supposed to be speaking and
just issue the condemnation of our article, just out of
the blue. So what was everyone so angry about. Anyway,
We were trying to estimate the proportion of this in
(01:55):
the United States that were associated with different bm I levels.
Cavin specifically for a CDC division known as the National
Center for Health Statistics. That's the agency responsible for coming
up with data to help make Americans healthier, And like
Catherine said, she was focused on figuring out how many
(02:17):
deaths in America were associated with different b m I s,
or body mass index, which is basically a mathematical formula
for estimating a person's body fat. In other words, Catherine
was investigating the link between weight and death. But these
(02:39):
weren't just numbers something to stick on a website or
pamphlet somewhere and forget about a lot of things done
at the National Center for Health Statistics are supposed to
influence policy. At the time, body weight was already emerging
as public health enemy number one. The deadly impact of obesity.
(03:02):
The toll on Americans far greater than previously thought. Why
are Americans so fat? The United States is the world's
baddest developed nation, with an obesity right double of that
in many European countries. The CDC had declared obesity a
growing epidemic years earlier, and Catherine and her colleagues weren't
(03:26):
the first to look at the subject. The paper that
came out before ours estimated that obesity was about to
overtake smoking is the major cause of death in the
United States. Remember, at this point, there was also tons
of awareness that smoking is bad for you, So the
idea that being heavy could be more dangerous than smoking
(03:49):
that really sent people into a tail spin. It looked
like America had this big weight problem. But when Catherine
and her colleagues sat down to do their own analysis,
they came to a very different conclusion. Our paper didn't
suggest that the city associated deaths were anywhere. They're likely
(04:10):
to overtake smoking as a major cause of death. Using
data from what's called the National Health and Nutrition Examination Survey,
they examined the health of tens of thousands of Americans.
They also tracked how many of those participating over the
years had died. If you look at the number of
(04:31):
deaths and you adjust for all these things like age
and gender and socio economic data and so on, we
get this many more desks than would be expected, and
this many fewer deaths would be expected, making that comparison
to normal weight. They basically wanted to figure out how
many more people considered overweight or obese we're dying then
(04:53):
would have been expected if they had been at a
so called normal weight A. When they crunched the numbers,
Katherine and co. Found that obesity wasn't about to pass
smoking as a top cause of death in the US,
not even close. They also found that the number of
(05:14):
deaths connected to higher b m I s is actually
pretty low, so it was a very different result. They
find that fewer people with a b m I classified
as overweight We're dying than would have been expected at
a normal weight b m I. We didn't say that
these things are caused or were protected, or that or
(05:37):
we is protected. We just reported the numbers. Now, people
have a lot of takeaways from that, but I don't
feel responsible for all their takeaways. But to say the
least they're finding was really unexpected. After all, carrying around
extra pounds is supposed to be bad for you. That's
the whole basis for medical categories like overweight or obese.
(05:59):
This is the scientific foundation on which weight lost empires
have been built. Where did that idea come from? Anyway?
And is it even true? What Catherine and her team
found called at least some of this into question, so
other scientists freaked out. It seems like they decided the
(06:23):
only explanation was that Catherine and her team had messed
up somehow. That was easier for them to swallow than
considering the opposite, that Catherine and her team could actually
be right, that the relationship between weight and health could
be different. The funny thing is this Catherine and her
(06:48):
colleagues hadn't meant to call into question the very foundations
of weight science. We just blundered into this. I mean,
we weren't trying to cause a fire. Back to what
Catherine and her colleagues found, It wasn't that there was
no link between b m I and death exactly, but
(07:09):
that link existed among people with higher b m I
of thirty or higher, which is the cutoff for obesity,
and especially thirty five or higher, and when the researchers
added it all up, the total number of deaths tied
to these categories of overweight and obees turned out to
(07:33):
be pretty small. More people were dying in those years
from car crashes and gun violence, and more people were
definitely dying from smoking, so there was a very large difference.
Before Catherine published the research, she also looked at a
bunch of other studies. She wanted to know whether her
(07:56):
team's findings were unusual. After all, their paper contradicted what
most people think about weight and health, at least when
it comes to the category of overweight. But it turned
out that there's wasn't even the first study with findings
like these. There's a lot of other studies that have
(08:17):
shown this already, so it's not a big deal. Those
other studies had also found little risk of death associated
with having a b m I classified as overweight, But
it was Catherine's study that for some reason really struck
a nerve, and a lot of those tacks were coming
from academics at one particular institution, Harvard, especially this one
(08:42):
guy Walter Willet. At the time, Walter was the chair
of the nutrition department. After another paper, Catherine wrote, he
went around calling her work a pile of rubbish and
said people should ignore it. The prestigious journal Nature actually
(09:03):
ended up writing an editorial basically criticizing Walter's comments and
saying he was oversimplifying the science. But there was more
than just that. And then the Harvard School of Public
Health group that was mainly, although not exclusively, the antagonists here,
(09:23):
they decided to schedule a symposium at Harvard to basically
to show what was wrong with my article. That's right.
Researchers opposed Catherine's findings so fiercely that they put together
a whole event just to talk about how much they
hated it. And Catherine says that the conference organizers didn't
(09:44):
even make it possible for her and her co authors
to attend. As you can imagine, all of this was
a lot for Catherine. This is getting really stressful. I
had a very high adrenaline level, I would say, because
I was always finding the weird attacks in places that
I just would not have expected, like Wikipedia. The gist
(10:04):
of all this criticism was that there were things Katherine
and her colleagues had simply missed. They had found. The
people living in bigger bodies were dying at similar rates
to those in smaller bodies. But like I said earlier,
it was easier for prominent scientists to imagine that Katherine
and co. Were wrong, then that they're finding could be true.
(10:28):
The explanation critics landed on, according to news coverage at
the time, was that their numbers must have been off.
After all, people can be thin because they're sick with
diseases like cancer, or because they're elderly. The critics said
that these sorts of things must have thrown off the study.
(10:52):
They also said that Katherine's team didn't use enough long
term data, but Katherine says, no, that wasn't it at all.
The issue was that people had already meet up their
minds about weight and health, and Catherine was undermining those
preconceived notions. Catherine was basically an atheist, renouncing the gospel
(11:16):
about weight and health. There's this real drive to say
anything finding like that is unusual. It needs to be
explained away. We need to get rid of this. How
do we get rid of it? We've got to say, well,
maybe it's because of ages, or maybe it's because of this.
It's because of that, you know. So there's all you
have to explain away in convenient findings. Catherine says this
stuff wasn't really an issue, and in fact, she and
(11:40):
her team said right in their paper that factors like
illness and duration of follow up didn't have a big impact.
So this was all based on pretty much nothing, But
it was very influential, and this kind of stuff went
on literally for years. Disagreements like these are actually a
really key part of the scientific process. The whole point
(12:04):
is to go back and forth about findings so people
can trust that they're accurate. But the way Catherine describes it,
the criticism crossed the line. What could have been a
legitimate scientific debate evolved. Misinformation started flying, Like when one
group claimed that Catherine's findings were renounced by the CDC,
(12:29):
she says they weren't. When I asked the CDC about it,
they didn't get back to me. So there's just all this,
at least falsehoods lying around, and I didn't know what
to do about them. Some of it was just kind
of disrespectful about Catherine's skills as a scientist. The one
who was kind of insults saying that my paper was
(12:50):
my faintly flawed. That was nonsense. It was rubbish, that
we made very simple errors that were completely wrong. Harvard
didn't return a request for comment by our deadline. In
an email to me, Walter Willett said that Katherine's paper
quote was causing serious confusion among physicians and patients, with
(13:11):
potentially dangerous clinical and public health consequences. He also says
that many large analyzes have refuted the findings showing that
overweight and obesity have poor health effects. It's clear from
talking to Catherine that these criticisms rankled her because she
(13:31):
cares a lot about the science. She retired from the
CDC in and is currently a consulting professor at Stanford.
But the attacks became personal too. Lisa and Darovitch, who
was a PhD student at Harvard about a decade ago,
(13:51):
said a professor there even criticized Katherine's weight, saying that
was why her work couldn't be trust stid. I got
very stressed trying to deal with this stuff and trying
to respond to things that people were saying. This was
Catherine's scientific reputation on the line, This is her career,
(14:13):
and this loud chorus of scientific feedback is saying legal
must be wrong. Legal is wrong. Legal is wrong. She
must be wrong, or this must be wrong, or therefore
she's wrong. But what if Catherine wasn't wrong? What if
the dangers of being heavy have been overstated or misrepresented?
(14:34):
A small but vocal contingent of experts and advocates say
just that. They argue that weighing more isn't inherently bad
for you. In fact, when people say that, they are
mixing up correlation and causation, a classic scientific error. This
is obviously counter to the predominant thinking. But the idea
(14:58):
here is that we have been folk using on the
scale too much and not enough on healthy behaviors. Our
weight bias has become a major blind spot, something that
keeps us reciting the same old lines about weight and health,
even as a body of scientific evidence suggests that this
(15:19):
way of thinking is wrong. We're going to get into
that in this episode, and we're going to take a
close look at evidence behind it. I'm Bloomberg News health
reporter Emma Court and from the Prognosis podcast This is
Losing It. There's some things pretty much everyone will agree
(15:51):
is true. The earth is round, the sky is blue,
and weighing more is bad for you. That's the message
we get in a million overt and subtle ways every
single day. Just look at who gets featured on the
cover of fitness magazines. And then there's the actual messages
(16:15):
people with bigger bodies get from their doctors, from friends
and family, and even sometimes from random people on the street.
Lose weight and you'll be healthier. Tracy Man, a psychologist
who runs a health and eating lab at the University
of Minnesota, puts it really well. The air we breathe
(16:39):
is weight stigma. Treating people in bigger bodies poorly is
so common that lots of people don't even notice it
or think of it as discrimination. We've been brought up
with views that it's not okay to be obese and
that you need to be thin, and you, at least
a minimum need to be trying to be thin. Tracy
(17:02):
thinks that's why diets keep getting pushed over and over
and over again, even though they don't really work for
long term weight loss, not for most people anyway. Like
she says, even if the deck is stacked against you,
the expectation is that you should at least try to
be thin. The message is persistent. Getting thin should be
(17:25):
your goal, otherwise you're doing it wrong. The way Tracy
put it really struck me. Wait, stigma is the air
we breathe, and so is the idea that living in
a bigger body means you're unhealthy. Think about it. When
did you first hear that weighing more is bad for you?
(17:50):
And how often have you heard it since then? Every month,
every hour? Did you ever question why that's the case
or have you always just accepted it at face value?
I'm guessing that for most of us it's the latter.
I've just heard it said that that you can be
(18:11):
fat and healthy. Actually you can't think. I'm sure that
you're excess if that is unhealthy, I don't think anyone
is agons off with it. But how do we know
that being heavy is bad for you? Tracy and others say,
we actually don't. We don't know that. We know that
(18:32):
people at heavier weights can have health problems, but they
don't always, and it's not clear that weight itself is
the issue. Here's the deal. Higher B M E s
are at greater risk for a lot of different diseases,
medical conditions, and depth. It's a really long list, so
(18:56):
I'll just read it off the cdc S website. High
blood pressure, high cholesterol, type two diabetes, coronary heart disease, stroke,
gall bladder disease, ost arthritis, sleep apnian, breathing problems, many
types of cancer, mental illness like depression and anxiety. You
(19:18):
get the idea. You hear this kind of thing all
the time, like from doctors who say, all of the
chronic diseases that we deal with, high blood pressure, cardiovascular disease, diabetes,
they're all related to weight problems. The CDC also lists
some more vague sounding things as risks if you're heavier,
like low quality of life and body pain and difficulty
(19:42):
with physical functioning. You might be wondering what the connection
is between weight and all these problems, the why of
it all. Doctors and scientists are specifically concerned with extra fat,
which they say can put lots of stress on the body,
(20:04):
including pressure on bones and joints, and fat cells can
lead to inflammation, affecting things like regulation of blood sugar levels,
which can lead to diabetes. But again, the conditions I
listed earlier are risks associated with higher weights, Like the
(20:25):
doctor we just heard talking said, heart disease and diabetes
and all the rest are linked with weight or associated
with weight the reason for all that careful language. Here's
tracy again. Weight is correlated with many problems, but correlation
(20:47):
does not mean it's causing those problems. Correlation is not causation.
That's kind of a big rule in statistics. Admittedly, I
haven't been in a math class in a long time,
but I remember pretty clearly that in high school one
of our teachers actually had us banging on our desks
(21:09):
and enchanted. Correlation is not causation. Correlation is not causation. Now,
there are a lot of places where conflating correlation and
causation becomes a problem. One of the classic examples has
to do with ice cream and murder. Ice Cream sales
(21:31):
increase in the summer, and so do the number of murders. Therefore,
ice cream causes murders. Seems straightforward enough, but of course
that's wrong. Murders and ice cream consumption both go up
at the same time because of a third factor, rising temperatures.
(21:54):
When it's warm, people eat ice cream, and just generally
people are out and about more. They're doing more of
lots of kinds of activities, including apparently committing felonies. Ice
Cream may be delicious, but it is not to blame again,
Correlation is not causation, and with weight, just like with
(22:18):
ice cream and murders, there are other factors that could
help explain what's going on, things like lifestyle. More on
that in a minute. We want to understand why so
many diseases occur so we can prevent them, and many
diseases are associated with weight. Studies have also shown that
(22:44):
when people lose weight, they lower their odds of developing conditions,
including diabetes, and improve things like cholesterol levels. Evidence seems
clear right losing weight is the way to improve your health.
But the experts and advocates I spoke with for this
(23:06):
episode tell a very different story. They say that we
unfairly blame weight for really complex scientific questions and treat
dieting as a quick fix. Except it's actually not a
quick fix because, as we've learned in this podcast, losing
(23:28):
weight long term is a really challenging and almost impossible enterprise.
So what could be actually causing these diseases and other
issues if not weight? Now, this is a subject that's
really charged, so I ask you to reserve judgment. Here
(23:52):
are experts out. It turns out that there are a
lot of things that are correlated with weight, aren't so
good for you, including being sedentary. Sedentary a k a.
Not moving around a lot. This is actually a pretty
big issue, and not just for people at heavier weights.
(24:14):
Many many people live sedentary lives. We drive to work,
we sit at a computer, that kind of thing. In fact,
people in the Western world have been living like this
for hundreds of years. We talked about that in episode two,
how the Industrial Revolution shaped the conditions of modern life
(24:34):
and modern dieting and made us all a lot more
likely to just sit around on our butts all day.
At a certain point, it starts to get tough to
separate out how we live from how much we weigh.
You get into a little bit of a chicken or
egg thing. Here's Glenn Geyser, a professor of exercise physiology
(24:56):
at Arizona State University. People who are overweight or beasts
tend to be less physically active. They tend to eat
unhealthier diets. That is on average what we see. But
that doesn't mean that the weight is the problem. Means
that it's probably the lifestyle. The problem is lifestyle, not weight.
(25:18):
This is the problem that we have in America. We've
got this disconnect. We think weight is the big issue
when it's really not. It's the lifestyle that oftentimes goes without.
Of course, weight is way more complicated than just lifestyle.
Not all of it is in our hands. Your genetics,
for example, are a really important factor too, but you
(25:42):
can actually change your lifestyle. Higher weights are also connected
to other things too. Here's tracy again. It's also correlated
with poverty, and there's a ton of research showing links
between poverty and health problems. Heavier people also experienced stigma.
(26:04):
Often they're treated worse because of how they look. That
has been shown to be correlated to health problems, even
controlling for whatever the person weighs, and there's lots of
reasons for that. People in bigger bodies often go to
the doctor and just get told to lose weight, almost
as a reflex. Doctors just assumed that weight is the
(26:28):
issue and don't investigate what might actually be causing someone's
health issues. And when things like that happen, people get
sicker and they also avoid doctors. That's wait stigma in action.
Wait stigma is incredibly prevalent, not just for medical providers.
(26:50):
Doctors are the number two source of fat phobia and
wait stigma outside of family. This is Veronica Garnett. Veronica
is a dietitian and one of the leaders of a
group called the Association for Size Diversity and Health or ASDA.
And then if you're in a fat phobic we live
in a fat phobic society and world. It is stressful
(27:11):
to be treated poorly because of the way you look.
Lots of evidence has suggested that stress is not good
for people and can have all sorts of terrible effects
on their health. It starts to feel like some kind
of vicious cycle. We assume people's weight makes them unhealthy,
(27:31):
and those assumptions then harm their health. It's also stressful
to navigate a world that, just in general, was not
designed to accommodate your body. Here's Annie Jansen, another one
of asda's leaders. Annie is also a dietitian and has
a master's in public health. Fat people's health is impacted
(27:54):
by fat phobian weight stigma. Even outside of the medical realm.
Chairs are are not accessible to all people. In restaurants,
um and theaters, and other public spaces. UM people face
direct hate and comments about their bodies when they're out
in public, limiting their ability to participate in public life.
(28:17):
Doctors are people affected by bias like any other person,
and bias can also affect the scientists doing the studies.
It's easy for people to find diseases correlated to higher
weights when the research itself is biased um, and it's
easy for people to accept that and not really be
(28:37):
critical about how well done those studies are. There's one
more thing, a really important thing. As we've established by now,
people who live in bigger bodies are facing all this
pressure to diet and lose weight. Losing weight isn't usually sustainable,
though so many people gave weight back. This is known
(29:03):
as yo yo dieting, or, in more scientific terms, weight cycling.
There's actually a lot of evidence connecting it with health problems.
Weight cycling is an independent risk factor for diabetes, hypertension,
insulin resistance, and a slipidemia, which is essentially high bad
cholesterol and or good are low good cholesterol. You'll notice
(29:27):
that all of those disease listed are typically diseases associated
with higher BMI. This is again something that studies have found.
I know you're sick of me saying it, but correlation
is not causation. So how come with weight we've thrown
out this incredibly basic scientific principle. A lot of doctors
(29:50):
and scientists would say that we have it, and that
there's clear evidence extra weight harms health, evidence like the
way people's health and prooves when they lose weight. But
as I spoke with sources for this episode, I began
to wonder whether we're just more willing to let correlation
(30:11):
equal causation when it comes to weight, because we've already
convinced ourselves that being thinner is better. By the way,
not all of the findings about higher weights are bad.
When it comes to a variety of diseases like heart disease, cancer,
(30:31):
and diabetes, research has found a connection between obesity and
longer survival. In other words, it looks like when heavier
people get sick with these diseases, they actually might be
less likely to die. This is again an association correlation.
(30:55):
We can't go as far as to say that weighing
more is the reason people with these diseases survived longer,
though some scientists have said they think that could be
what's going on, and longer survival is of course a
good thing. Still, these kinds of findings don't go on
(31:18):
the CDC website under obesity. Remember that long list of
medical conditions associated with higher body weights. The government's web
designers don't like go edit the page and add an asterisk.
If they did, the website might say overweight an obesity
(31:39):
put people at higher risk for diseases like diabetes asterisk.
But people in bigger bodies who get diabetes actually live
longer than people in smaller bodies with the same disease.
Weighing more is supposed to be bad for you, and
yet in certain cases it doesn't look bad for you.
(32:02):
That's called the obesity paradox, and it does at some
levels seem pretty paradoxical. But let's become a term that's
used for just anything that shows obesity is good for
you or might not be so bad for you as
a paradox. Why is it a paradox because you don't
expect it. That was Katherine Flegal again from earlier. Everyone
(32:26):
already agrees that being heavy is bad for you. Anything
that counters the narrative, well, it must be a paradox.
Catherine's research also ran counter to the mainstream narrative, and
a lot of people went to a good deal of
trouble to discredit it and discredit her. But remember how
(32:48):
before she published, Catherine went through other scientific papers. She
actually found that a lot of articles had similar findings.
That's why she was so surprised by the reaction to
her paper. If that's the case, why did Katherine face
this big wave of criticism and bad feedback about her
(33:09):
work for years afterward. Now, when I look back, I
realized that most articles kind of like ours, would not
would not just publish the numbers they would come. They
would start with something, well, everybody, it's really bad for
you because it causes like X, y Z, And they
would have all and it costs all us money. But
even though it costs all us money, it is so
bad for you, and less found this number, but don't
(33:30):
pay any attention to it. In other words, most researchers
would open their studies with a long disclaimer saying that
extra weight really is unhealthy, even if that isn't exactly
what their research suggested. I took a look at some
of the scientific papers about the so called obesity paradox,
and a lot of those articles are kind of like
(33:52):
that too. They open with some variation of obesity is
a big, big problem, will be to be bad. Obesity
kills people. I'm paraphrasing, of course, and then the studies
go on to say that patients with diabetes who are
heavier actually die at lower rates, that when they get
(34:13):
cancer they actually survive longer. To me, this is a
story about bias, how it can affect even scientists who
are supposed to be led by just the facts and
the data. It's also a story about group think. Once
there's a narrative out there and it's firmly settled, people
(34:34):
don't want to complicate it. What if they're wrong, They
would look pretty stupid. Catherine points out another piece of
this that scientists are people too, people who have specialized
in an area and get money to study it and
whose career advancement depends on it, and like anyone else,
(34:57):
scientists have goals, power, funding status. I think it would
be career ending. Career ending. She's saying that because of
how ferociously her work was attacked. That's what happens when
you complicate the narrative about wait, or even when you
(35:18):
undermine it. It's worth pointing out that complicating the narrative
didn't end Catherine's career. Those things did get pretty unpleasant,
but Catherine's career at least was protected. We were all
senior government scientists that inn that we couldn't really be fired.
We didn't depend on grants, and we didn't need to
get tenure or anything like that. We couldn't be promoted
(35:40):
any higher. She says, it would have been a whole
different story if she was an associate professor somewhere. I
would never want any grants. That would have ruined my career.
It was only later that Catherine started thinking of this
whole dust up a little differently. It felt like her
fellow scientists had taken a side on the issue all,
almost as if it were a political campaign. I actually
(36:03):
was surprised the first of my thoughts I heard someone
mentioned the idea of sides, like I don't have a side.
This is the data we use, these are the methods
we use. It's not a side. It's not a statement
of opinion. It's not like personal opinion. It was like
Catherine's fellow scientists had decided being bigger was bad for you, period,
no nuance, no questions about it. It's been fully established.
(36:29):
Any data that contradicts it, that data can just shove
right off. So to summarize, the idea that weighing more
is bad for you is incredibly prevalent, but well, it's complicated.
In fact, there's a group of researchers and advocates who
(36:51):
argue that the dangers of being heavy have been exaggerated.
They say we've scapegoaded weight for diseases when there could
be other causes, like a lack of activity or not
eating particularly healthily. And when scientists put out research that
suggests being a little bigger isn't so bad, they face
(37:14):
these vigorous attacks from really prominent people for years. All
this brings us to the billion dollar questions can you
be healthy at higher weights? The experts we spoke with say, yeah,
you can be. Something that we actually can solve is
(37:36):
how to make people healthier. Much easier to make people
healthier than it is to make people thinner. I'd say
this all the time, and I don't know why it's
so radical a thing to say, but behaving in healthy
ways will make you healthier. It just won't necessarily make
you thinner. Healthy behaviors like exercising, eating our vegetables, getting
(38:01):
lots of sleep, and reducing stress, even if those things
don't make us lose weight, which they may not. Here's
Glenn Geeser, the Arizona State University professor again, and at
some point in our life we have to kind of
just say, look, this is my weight. This is about
it for me. I'm just gonna have to settle for this.
(38:22):
But that is not the same as saying, look, I'm unhealthy.
I'm just going to have to settle for this. Because anyone,
regardless of their weight, can improve their health with lifestyle change,
and as obvious as it sounds, people at all different
weights do all different levels of these healthy things, which
(38:42):
is part of the reason it's so wild we group
people together in these broad, undifferentiated categories. It's like telling
everyone who is at a so called normal weight, you
get a free pass vegetables. Who needs them stay at
that weight and it doesn't really matter what you do.
(39:03):
B m I stigmatizes those who get classified as overweight
or obese because of it, but so called normal weight
people are also getting led astray by b m I
because they might think they're fine and don't have to
exercise or anything, even though their lifestyle might be putting
them at risk. Everyone is getting screwed. Someone who is
(39:27):
classified as overweight or obese by the body mass indexed criteria,
but exercises a lot and has a modest, at least
a modest level of fitness. They tend to be better
in terms of overall health outcomes than thin people who
are very sedentary. So fitness matters, fatness not so much.
(39:51):
That's great news for jim rats around the world. But
here's the thing. All those classic healthy things I just
listed off earlier, lots of people aren't doing them. This
isn't me being judgmental. All that stuff is really hard
to do the way society is set up. It's hard
(40:14):
to make time to work out. It's hard to eat
better when healthier food is way more expensive and inconvenient.
It's hard to sleep more and reduce our stress when
we lead busy lives and have stressful jobs. The world
we live in is not built to encourage or support
healthy behaviors, but there are things we could do to
(40:38):
change that. First, let's talk exercise. The US government recommends
a few hours a week of moderate cardio plus at
least two days of muscle strengthening. Most adults aren't doing that,
and the government actually tracks what people eat. How it
(41:01):
compares with dietary guidelines. That score has gotten a little
better over time, but it's still not great. In Americans,
eating habits rated a fifty ninety nine out of hundred
at some schools, that's a failing grade. What it means
(41:23):
is that we're definitely not eating enough vegetables, fruit, or
dairy each day, and getting the right kinds of grains
and protein like whole grains and nuts can be a
problem too. So people aren't moving enough and they aren't
eating so great. But then let's say they go on
(41:45):
a diet. They start exercising more and eating in more
healthy ways. They're doing those quintessential healthy behaviors, and the
most common ways to lose weight are through exercise and diet.
And remember are that laundry list from earlier, of all
the health risks tied to heavier weights. Doctors and scientists
(42:08):
will tell you that the way you reduce those risks
is to lose weight. But also, the funny thing about
diets is that sometimes when people go on diets, they
actually lean into a lot of those healthy things. So
now you have to ask the question, will wait a minute,
if people are exercising and dieting, when they lose weight.
(42:30):
How do we know that it's the weight loss that
improves the health and not the exercise and the healthier eating.
Glenn says that there are studies where people with b
m I is considered overweight and obese change their diet
and exercise, but don't lose much or any weight. And
(42:52):
why do you know these folks start looking healthier by
measures like lower cholesterol. And in study of what's known
as the Dash diet, which helps people reduce high blood pressure,
researchers actually prevented participants from losing weight. They did that
(43:13):
by weighing people and adding in calories when needed, and
people's blood pressure declined. Anyway, long story short, people can
improve their health without losing weight. Tracy Man from the
University of Minnesota says it's actually easier. It's really really
(43:37):
hard to lose weight and keep it off, but eating
your vegetables and getting your steps in that's within reach. Still,
it's kind of a tough sell, right You're telling me
to get on a treadmill or whatever, and I'm not
even going to drop a pant size. We need to
(43:58):
find a way to help people stick to those health behaviors,
especially physical activity thing. Two, we've got to get rid
of weight stigma, because as long as there's weight stigma,
people are going to keep trying to diet, and people
are going to continue to make obese people uh feel
bad and suffer in various ways that are unfair and unjust.
(44:19):
Um And three, we need to find a way to
help people feel satisfied with whatever body they have once
they are behaving in healthy ways consistently. That body won't
necessarily be thinner at then as you want, but that's
your healthy body, and we've got to find a way
to be satisfied with that. Freecy's Lab at the University
(44:40):
of Minnesota is working on those right now. Adding vegetables
to your diet um and especially doing the recommended amount
of physical activity each week. Those are lifestyle changes and
people should do them. Again, doing them doesn't mean you're
gonna lose weight, Doing them doesn't mean you're going to
be thin, and but doing them does mean you will
(45:02):
improve your health. You have to measure health in a
different way now at the scale, approaching health in a
way that's way inclusive. There's actually a movement behind it
called you Guessed It Health at every size. What we're
(45:23):
trying to do currently, and the current mainstream approach to
health and weight isn't working. This is Annie again from
asda as that advocates for health at every size. What
we see in the research is that efforts to make
that people thin are failing. They fail over and over
and over again. We have decades, literal decades of research
(45:46):
and so those are not things that people can just
choose to do, like they could choose to eat more vegetables.
And so what what happens when we shift the focus
to things that people actually have control over, like what
they eat, or how they move their bodies or web
or not they smoke any Veronica and their fellow activists
are fighting for exactly that, for people to stop treating
(46:08):
weight as the equivalent of health. They say that we've
been telling people to lose weight for their health and
that's not only wrong, but it's actually causing a lot
of harm. The vast majority of doctors today are still
very fat phobic. Ultimately, we need healthcare practitioners to understand
(46:29):
what the science really does say and and right now,
the science is contrary to what the mainstream beliefs about
fatness are. And if a fat person is going to
get good care in the hands of a doctor. We
need people to also understand what the science and research
says about weight and weight loss. This is again contrary
to how society still thinks about things. Any points out
(46:51):
that just having a certain b m I, a b
m I that's considered in the obese range, is now
itself being called a disease. But the activists at ASDA
are fighting for more than that too. Veronica and Annie
argue that even the idea of health itself is broken.
(47:12):
After all, how did scientists come up with standards for health.
They did it by mostly studying white heterosexual men. We
are trying to shift the way that we talk about
health in health at every size so that we don't
continue to uphold those white centric, erocentric um standards within
(47:33):
our own movement. One way to think about this is
in terms of how much we value health as a
society and what that really means. Health is often defined
as the absence of disease right off the bat. That
leaves a lot of people out, and on top of that,
some of the sickest people in society are also the
(47:54):
most marginalized people like people of color, LGBTQ people, more people,
A fat person, uh could live this healthy, long, happy
life according to these Western Eurocentric standards of health. Right,
this is Veronica again. But let's say they don't. Let's
say a fat person does develop diabetes, then what do
(48:15):
we do? Do we not care for this person? Are
they just disposable? Um? And like a lot of times
it plays out in our medical industrial complex, like fat people, uh,
disabled people, aging and chronically ill people are just seen
as disposable. And like if we look at the pandemic
that we're living in, some people were just left to
(48:36):
die or people like, oh, well, it's only this COVID
is only affecting certain people, so like I don't have
to worry about it, and those people could just get
sick and die. But is that the type of world
we want to live in? Is that the type of
health care system like we want to uphold? Veronica says
that ASDA wants to change these things to people, no
matter what size they are or what health can soon
(49:00):
as they have or don't have, or whatever deserved care,
they deserve equitable, barrier free access to the care and
resources they need to support their well being. I wonder
like what our health care system would look like if
we actually just all acknowledge that being sick, being like,
becoming disabled, being disabled, getting old and dying is a
(49:24):
normal part of the human experience. That means getting the
message across about health and we isn't enough. Historically, the
movement has really promoted this idea that we just need
to get healthcare professionals to stop prescribing weight loss and
to stop using BMI as a measure of health and
(49:46):
kind of like we'd be good, like we'd be done.
And honestly, this promotes a very white centric view of it,
because for a fat white person, if you can eliminate
that barrier, all of the sudden, you have health care
that affirms you. But and he says that isn't the
(50:07):
case for lots of other people, including black people, trans people,
and disabled people. That's changing what their organization fights for,
things like who gets a seat at the table when
people are doing research. The way health insurance is structured
use of b M I to access health care services
(50:28):
like surgery. And now I think what we're shifting to
is really this understanding that the way that we define
health as a society, the way that we define it
when we study it in our research studies, and the
way that the health care systems engaged with people are
(50:48):
barriers on so many levels that we need to start
dismantling and reconstructing the whole thing because they were based
on one kind of person. It's not just our ideas
about weight and health are wrong, it's that they are damaging.
We can all be doing a lot more to shift
how we think about these things and to make the
(51:10):
world a better place for people in bigger bodies. As
we do that, though, we've still gotta eat. And the
thing about eating is that we've gotten pretty messed up
about it. All. This talk about what's good for you
and what's bad for you really does a number on people.
Diets put so so many rules and food, and they
(51:34):
can be incredibly hard to unlearn. If we put the
diet to rest, stop making weight loss the goal, then
what is there a way to be satisfied and healthy
in whatever body we've got With self care, self compassion,
tuning into hunger, fullness and enjoyment satisfaction, our bodies are
(51:56):
going to be what they're going to be, and it's
about learning how to be liberated from a belief that
you have to change your body in order to be acceptable.
Next week, on the final episode of Losing It, we
dive into the world of intuitive eating. The scale is
just a false idle and what we lose when we
try to lose weight? What would you spend those on?
(52:20):
What passions do you have of? What creativity would you
spend it on? What hobbies? What you know? Spending time
of loved ones? Like what would you do if you
got that time back? Getting rid of diets? Eating without
thinking about weight? Is that even possible? Losing It is
(52:41):
written and reported by me I'm a Court and edited
by Kristin B. Brown. Magnus Hendrickson is our senior producer,
Stacy Wong our associate producer, and Blake Maples is our
audio engineer. Our theme was composed and performed by Hannis
Brown thanks to Francis A. Leavi and Tim and Nette.
(53:02):
Be sure to subscribe to Prognosis if you haven't already,
and if you like our show, please leave us a
review that helps others find out about it. Thanks for listening,
See you next time.
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