With health care in the news, everyone's looking for magic bullets to save money. Obesity seems to be a growing favorite: wouldn't it be great if we could make everyone look like Jennifer Anniston, and be cheaper to treat? There are a lot of holes in this theory--the morbidly obese are very sick, but die young, while lower levels of overweight/obesity aren't so well correlated with poor health. But still, the idea's power seems to be growing every day.
This week, Health Affairs published a new study showing that--quel surprise!--obesity accounts for an ever growing share of our health care costs. They put the number at about 10%. So I decided to ask Paul Campos, the author of The Obesity Myth, what he thought. The book, which everyone should read, argues that the health benefits of losing weight are largely imaginary; that we are using "health" to advance our class bias in favor of thin people, particularly thin women.
Megan: The CDC is sponsoring a conference on obesity this week. In conjunction with this, the journal "Health Affairs" just published a study showing that almost 10% of US medical costs may be due to obesity. As we're debating the costs of a public health care plan, controlling obesity is moving even further to the forefront of the American public health agenda. What should we think of this?
Paul: It's a terrible idea on all sorts of levels. There are three big problems with attempting to control health care costs by reducing so-called "obesity." First, it's a fake problem. Second, the solutions for the problem are non-existent, even assuming the problem existed. Third, focusing on making Americans thinner diverts resources from real public health issues.
Megan: Let's start with the first. If there's one thing that everyone in America knows, it's that being fat is really unhealthy. Why do you call it a fake problem?
Paul: The correlations between higher weight and greater health risk are weak except at statistical extremes. The extent to which those correlations are causal is poorly established. There is literally not a shred of evidence that turning fat people into thin people improves their health. And the reason there's no evidence is that there's no way to do it.
So saying "let's improve health by turning fat people into thin people" is every bit as irrational as saying "let's improve health by turning men into women or old people into young people". Actually it's a lot crazier, because there actually are significant health differences between men and women and the old and the young -- much more so than between the fat and the thin.
Megan: So why is the public health community so set on this issue as the major driver of our health care costs?
Paul: Because we're in the midst of a moral panic over fat, which has transformed the heavier than average into folk devils, to whom all sorts of social ills are ascribed.
Megan: Aside from rising health care costs?
Paul: Well according to the obesity mafia our kids are all going to die sooner than their parents, which sounds like a moral problem as well as one of health care costs. It's all complete nonsense.
Megan: Do you think being overweight is a proxy for things that DO make a difference, like fitness?
Paul: It's a weak proxy, but yes it has some marginal significance. It's good to encourage people of all sizes to be active and avoiding eating disordered behavior (like dieting), but this isn't because lifestyle changes will make fat people thin people. They won't. I'd like to talk a little about the statistics if I may. : Please! We're all about statistics here.
Paul: OK, the CDC honchos and the authors of this study you referenced are in hysterics because the obesity rate, so-called, has roughly doubled in the last 30 years. But let's consider what that actually means.
Obesity is defined completely arbitrarily as a body mass index of 30 or higher (175 pounds for an average height woman). Now body mass follows more or less a normal distribution, whiich means if the the mean body weight is in the mid to high 20s, which it has been for many decades now, then tens of millions of people will have BMIs just below and just above the magic 30 line. So if the average weight of the population goes up by ten pounds, tens of millions of people who were just under the line will now be just over it.
This might be meaningful if there was any evidence that people who have BMIs in the low 30s have different average health than people with BMIs in the high 20s, but they don't. At all. So the "obesity epidemic" is 100% a product of tens of millions of people having their BMIs creep over an arbitrary line. It's exactly as sensible as declaring that people who are 5'11 are healthy but people who are 6'1" are sick.
Adding to the absurdity of all this, people with BMIs in the mid to high 20s actually have the best overall health and longest life expectancy -- ,more so than those in the so-called "normal" BMI range.
Megan: So we can't save billions of dollars by making people thinner?
Paul: Consider the methodology of this study. It tried to calculate changes in health costs if everybody with a BMI over 30 had a BMI under 25. But leaving aside the preposterous assumption that all increased health risks associated with a level of body mass are caused by that level of body mass, the idea that somehow we could make fat people into thin people is bizarre.
A study like this isn't talking about turning 180 pound women into 165 pound women, which at least in theory might actually be possible. It's talking about turning 200 pound women into 130 pound women, on statistical average. The success rate for such attempts is about .1% Even stomach amputation does not turn fat people into thin people.
So even if it were true that we knew it would be beneficial to turn fat people into thin people (which we don't) it's not something we have any idea how to do. The statements in the study indicating that there are known methods for doing this are simply lies of the most egregious sort.
Now lets talk about excess health care costs. if you look at the study, nearly half of the excess health care costs associated with being fat are from higher rates of drug prescription. But why are fat people being prescribed more drugs than thin ones? Largely, because they have the "disease" of being fat, which is then treated directly and indirectly by prescription drugs!
For instance, statins. Statins are a multi-billion dollar business, but there's very little statistical evidence that they benefit the vast majority of people to whom they're prescribed. Basically the only people who have lower CVD [cardiovascular disease] mortality after taking statins are middle-aged men with a history of CVD.
But the heavier than average are prescribed statins at higher rates simply because they're heavier than average, even though there's no evidence this is beneficial for them. And of course this doesn't touch on the costs of all the treatments for "obesity" itself, which are uniformly ineffective.
Megan: You're saying that increased risks from being heavy come from--what? Having gained weight in the first place? Bad genetics? Or dieting?
Paul: As for where the increased risks associated with being heavy come from (such as they are), many of them come from weight cycling, which is clearly bad for people, and which is the outcome of 98% of diets. Others come from the stress and social discrimination generated by having what's considered an inapproprirate body in this culture. Others come from diet drugs, eating disordered behavior, poverty -- all things strongly associated with higher than avberage weight.
Megan: What about gastric bypass? The quoted figures for gastric bypass seem pretty impressive when doctors talk about them on television.
Paul: Gastric bypass is surgically induced bulimia. People starve for the first few months so of course their blood sugar levels go down. At five and ten year followup the average weight loss from these procedures is about 10% to 15% of body mass (it's actually less than that since lots of people drop out of the studies) which means most of these people end up still "morbidly obese." And they can never eat normally again.Why do you think you never see the actual stats for weight loss from stomach stapling? If they were good they'd be on billboards 50 feet high.
Megan: Those shows on TLC that basically invite the audience to gawk at fat people usually say they'll lose fifty percent of their excess body weight
Paul: If you put people on starvation diets, which is what these methods do, of course you'll get huge amounts of weight loss. Then most or all of it will be gained back, which among other things is a recipe for congestive heart failure. I'd love to do a "reality" show on the contestants on shows like The Biggest Loser three years down the road. But that would probably be a little too much reality.
Gastric bypass is the most radical method available for weight loss, and it basically doesn't work. Everything else is even less successful, though usually not quite as dangerous.
Megan: Over the last five years or so, I've noticed that public health efforts about obesity are not just amping up the volume, but exploring increasingly coercive methods to induce weight loss: taxes on junk food, lawsuits against fast food companies (which are basically a tax on junk food), and so forth. Does that match your analysis?
Paul: It's the classic pattern of moral panics. As public concern about the damage being done to the fabric of society by the folk devils increases, increasingly intense demands are made on public officials to "do something" about the crisis, usually by eliminating the folk devils.
That of course is the strategy for this crisis. If fat people are the problem, then the solution is to get rid of them, by making them thin people. The most amazing aspect of this whole thing, for me, has always been the imperviouusness of policy makers, and even more so people who consider themselves serious academics and scientists, to the overwhelming evidence that there's no way to do this.
I mean, there's no better established empirical proposition in medical science that we don't know how to make people thinner. But apparently this proposition is too disturbing to consider, even though it's about as well established as that cigarettes cause lung cancer. So all these proposals about improving public health by making people thinner are completely crazy. They are as non-sensical as anything being proposed by public officials in our culture right now, which is saying something.
It's conceivable that through some massive policy interventions you might be able to reduce the population's average BMI from 27 to 25 or something like that. But what would be the point? There aren't any health differences to speak of for people between BMIs of about 20 and 35, so undertaking the public health equivalent of the Apollo program to reduce the populace's average BMI by a unit or two (and again I will emphasize that we don't actually know if we could do even that) is an incredible waste of public health resources
Megan: The idea I'm hearing now is that we need to change the environment, but of course, if losing a great deal of weight actually makes you unhealthier, that might not save us any money. The other idea I'm hearing a lot more these days is that we have to Save the Kids: intervene when they're young so they don't get fat in the first place
Paul: So the strategies that have failed so spectacularly with adults -- tell them to exercise more, and eat less, and shame them about their weight -- will work with children. Because if there's one thing fat kids need, it's to be made to feel bad about feeling fat.
The current stigmitization of fat kids is essentially child abuse as government policy, and the people behind it are, as far as I'm concerned, either incredibly stupid or very evil or in some cases both.
Here's an idea: Stop harrassing people about their weight. Because it appears that focusing on the idea that being fat actually makes people fatter. At least there's an extremely strong correlation there. I bet if we stopped demonizing fatness people would actually be a bit thinner. They'd certainly be happier and healthier
Megan: What should we do instead if we want to reduce health care costs? Here are some proposed ideas I've heard:
- Taxes on soda
- New urbanism (make people walk more)
- Bring back physical education in schools
- Make gym memberships tax deductible
- Menu labelling.
Paul: Some of those ideas may have merit independent of whether they'll make people thinner (they won't). It's good to encourage physical activity, but NOT if the purpose of encouraging it is to try to make people thinner. Then it's counter-productive. People will be healthier if they're more active and don't smoke and if they avoid eating disordered behavior (like dieting in particular.
But Americans are actually very healthy and getting healthier all the time, despite the massive inefficiencies and dysfunctions of our health care system.
Megan: The problem is, almost no one actually does "healthy" activities to be healthy. If burgers made you thin, but clogged your arteries, I think 95% of the "healthy" eaters I know would consume one every day.
Especially since those people are generally young people with poor grasp of their own mortality. Eating "healthy" and then taking up free climbing doesn't make much sense.
Paul: Oh that's certainly true. The idea that people pursue thinness primarily for health reasons is laughable.
Megan: They often actually claim they don't care about being thin. It's just a happy side effect of their drive for health. Indeed, I'm sure I've made that claim myself more than once while on the quasi-permanent diet of the Upper West Side woman.
Paul: It's pretty much the opposite though. I know for a fact (because they've told me) that some public health officials engage in what they think of as a noble lie about the effects of physical activity on weight, because they know people won't become more active just to be healthier.
Megan: Is there any evidence this works? Don't people just stop going to the gym when they notice they haven't lost any weight?
Paul: Of course. People aren't dumb. They do the experiment, the experiment doesn't work in the vast majority of cases, so they quit until they get desperate again. Or (llke the upper West Side women) they stay on a permanent restricted lifestyle that the vast majority of people don't have the combination of willpower and social privilege to maintain. There's an important class angle here. Thinness is a sign of social status, and is to some extent a product of it, which is one reason -- probably the main reason -- why it's so prized, especially among women.
Megan: An economist recently pointed out that we don't encourage people to move to the country, even though rural people live more than three years longer than urban people, and the diffefence in their healthy life expectancy is even more outsized. Nor do we encourage people to find Jesus or get married. We target "unhealthy" behaviors that are already stigmatized.
Paul: Right, as Mary Douglas the anthropologist has pointed out, we focus on risks not on the basis of "rational" cost-benefit analysis, but because of the symbolic work focusing on those risks does -- most particularly signalling disapproval of certain groups and behaviors.In this culture fatness is a metaphor for poverty, lack of self-control, and other stuff that freaks out the new Puritans all across the ideological spectrum, which is why the war on fat is so ferocious -- it appeals very strongly to both the right and the left, for related if different reasons.
Megan: And now a convenient scapegoat for our health care costs: if we can just eliminate the folk devils, we can have a new national health care program, and more room on the bus, for free!
Paul: Yes it's a low-calorie free lunch.
Megan: If you were put in charge of reducing the costs of the new plan that we may or may not get, is there anything you would do? Preferably instead of lecturing people about their avoirdupois?
Paul: One thing I've learned over the past 20 years of studying about four issues in great detail is that it takes an enormous amount of work to have a meaningful opinion on any complicated issue. I don't have anything useful to say about what sort of health care policy we ought to have, because I don't know enough about the subject. So I don't know what we should do in general. I do know what we should do about fat, which is to stop talking about it. If I were emperor I would ban scales from all homes (just kidding -- sort of)
Megan: Probably have a hard time getting that past Obama's proposed health commission.
Paul: Or anybody else's. I do want to mention that I think a huge factor in all this stuff is the desire to get the next generation of diet drugs through the regulatory pipeline. That's the goose that will lay the golden eggs for so many interested parties.
Megan: Well, here on the east coast, it's lunch time, so I'll let you go. Thanks for talking with us.