SARAH MCCAMMON, HOST:
Every year, millions of Americans go on a diet. Americans also spend billions of dollars on weight loss products. So why, despite all of that, are obesity rates in the U.S. are continuing to rise?
AUBREY GORDON: It's an incredibly complex issue that we don't actually have answers for, but we continue to sort of use the rising rates of fatness in our culture as a cudgel to get folks to lose weight.
MCCAMMON: That's writer Aubrey Gordon. She co-hosts the podcast "Maintenance Phase" with journalist Michael Hobbes. And she says when they first started, they wanted to focus on big questions. That other health and fitness podcasts weren't necessarily asking
GORDON: Felt worth having a conversation about, like, OK, well, what's actually the science behind this? What are the motives of the people who are presenting all of these fad diets, all of these wellness trends? Like, what's the story behind it?
MCCAMMON: I spoke with Aubrey Gordon and Michael Hobbes the other day, and we started by talking about the medical consensus that obesity can lead to health problems.
GORDON: Yeah, there's a very clear correlation between weight and bad health outcomes, but weight is not the only thing that's correlated with health. We know that poverty has a devastating effect on people's health. The life expectancy in various counties in America can be up to 20 years of difference. The poorest, most marginalized counties in America, people live to about 65. And, like, I think it's, like, Boulder, Colo., or something, they live until they're 85. There's all these other health disparities that sort of we accept as correlations.
And yet, weirdly, when it comes to obesity, it's like, oh, no, no, we know that the obesity is causing this, right? Like, people have kind of jumped to this causal explanation. And there is a very strong association, but there's very strong associations of all kinds of things with health outcomes. So the question is, why are we still putting weight at the center of our understanding about health when there's actually much more sophisticated ways to help people be healthy and we're not really doing those?
MCCAMMON: You spend an episode looking at how obesity became defined not just as a risk factor for certain diseases, but eventually as a disease in and of itself. Can you just give us a nutshell version of how this happened?
GORDON: I mean, I think in order to talk about, quote-unquote, "obesity as a disease," you've got to talk about the BMI, which I think we think of now as a hard and fast measure and an objective measure of size and health. The first BMI sort of public policy definition of overweight in the U.S. was that the fattest 15% of us should be considered overweight. That wasn't attached to their specific health outcomes that happen at that point. It was just, we're going to call the fattest 15% of us overweight.
Essentially, what happened here is that there was a public health person at the CDC who felt really passionately that our conversations about weight and weight loss were woefully over-simplistic. And he thought that redefining fatness as a disease would lead folks to understand that it's much more complicated than just this sort of like hard driving kind of personal responsibility narrative that we get.
The challenge is, as he did that, a bunch of drug companies started to back his efforts because if more people were defined as fat, they would have more customers for their weight loss drugs and surgery. That's not to say that those products haven't worked for some folks and haven't produced weight loss for some folks, but it is to say that that wasn't a neutral medical decision that was uninfluenced by capital, right? Like any other industry - right? - in the diet industry and in the health care industry, profit motives are still at play.
MCCAMMON: I mean, isn't the goal of calling something a disease often to be more compassionate? I mean, we see this with the drug war - right? - to look at addiction as a disease, which implies it's not something that somebody's fault, necessarily. It's something that requires treatment, not punishment, not scorn.
GORDON: Yes. I think that was the intention of this person at the CDC. Paradoxically, and unfortunately, what we have seen in the years since that redefinition is a skyrocketing of bias against fat people. That has happened amongst health care providers. It has happened amongst social workers. It has happened amongst the general public in the United States that we are seeing, you know, dramatically rising levels of anti-fat bias. So despite the sort of best intentions behind that redefinition, it has unfortunately produced the opposite.
MCCAMMON: I want to ask you both about something. You know, you talk a lot about how losing weight shouldn't be - probably shouldn't be the goal of making a change your lifestyle. You know, full disclosure, I'll tell you my own experience. About four years ago, I lost 60 pounds. I had gained weight during a stressful time in my life. It's complex, right? A lot of things went into it. And so I was at a much heavier weight than I normally was.
I very slowly and carefully without, you know, any kind of extreme changes began making small lifestyle changes in terms of improving the quality of my food, just going for a lot more walks. When I was heavier, I was still pretty healthy, but all of the objective measures of health, you know, like my blood pressure looks better than it did four years ago. And I just share this to say - and you won't offend me because I want to hear your honest opinion - is there a healthy way to think about weight loss? Is it ever OK for it to be a goal?
GORDON: I don't want to take anything away from anybody, right? I don't want to tell people who are, you know, sort of pursuing weight loss that that's a bad or unworthy goal for them. I do want to tell folks that that is a significantly more complicated venture than we have been led to believe that it is. The story that you just told was I changed the foods that I was eating. I changed the quality of the foods that I was eating. I changed the way I was moving and how much I was moving. And then I lost weight. And then my health markers changed.
So you can still do all of the other stuff. You can still produce changed health outcomes by changing your behaviors, and that may or may not result in weight loss. And that's still a win for your health, right? I think we would all do ourselves a really significant service by actually just focusing on the health markers and not the proxy for the health markers, which is weight.
MICHAEL HOBBES: The thing that we're interested in is at the systems level. So public health, we should not be aiming for weight, we should be aiming for health. If we're talking about medical care, a really important thing is for doctors to actually listen to patients. And if they want to have the conversation about weight loss, if a patient brings it up, I think that that is fine.
What we find is really consistent stories from fat people of going into the doctor with a migraine headache and their doctor tells them to lose weight. They go in with a car accident, their doctor tells them to lose weight. They go in with a tumor, their doctor tells them to lose weight. This is something that is, like, really, really devastating to the health of fat people that essentially people don't listen to them.
MCCAMMON: What, if any, feedback have you gotten from the medical community for your podcast?
HOBBES: Oh, it's like, unbelievably - it's some of the most disappointing emails I've ever seen. Like, it's like sentence by sentence. It's like this bias doesn't exist. And, oh, here's my bias. It is fascinating to me that like just a very basic thing - ask them about their diet and exercise habits before you tell them rote, boring advice like calories in, calories out. Like, there's so much resistance to this.
GORDON: So Mike tends to get the line by line, extremely overt bias emails. I tend to get the emails from health care providers who talk about things like, oh, my God, I had never thought about why I was required to put the BMI on every patient's chart, oh, my God, we're now talking about training for anti-fat bias and screening for eating disorders before we make any dietary recommendations to any patient. Like, every time Mike checks his email, the message he gets is doctors hate us. And every time I get mine - I check mine, I'm like, everything's changing, and things are looking up.
HOBBES: I know. We need to trade one of these days just for morale purposes.
GORDON: (Laughter) We really do. I don't know if I can handle it.
MCCAMMON: Michael Hobbes and Aubrey Gordon host the podcast "Maintenance Phase."
Thank you both so much for talking with us.
HOBBES: Thanks for having us.
GORDON: Thank you. Transcript provided by NPR, Copyright NPR.