Maintenance Phase - The Body Mass Index

00:00:00.000 we're ready i think you're up on intro yeah this one might be kind of offensive sorry in advance

00:00:16.660 uh welcome to maintenance phase the podcast that is just right between 20 and 25 too long

00:00:25.040 between 25 and 30 and morbidly too long from 30 to 35 oh god i just want to make the tagline of

00:00:32.500 our podcast just permanently like the podcast that is morbidly too long when you apply morbidly to

00:00:38.640 anything else you see how shitty it is yeah describe another person as morbidly anything

00:00:43.760 and see how that goes it's not gonna be great i am michael hobbs i am aubrey gordon and if you

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00:01:05.080 that and just continue listening quietly.

00:01:07.280 That's right.

00:01:07.960 So today, Mike, we are going to talk about the Body Mass Index, better known as the BMI.

00:01:13.340 Dude, I'm so excited.

00:01:14.480 I am really excited too.

00:01:15.860 We did a whole episode on Bamo stuff, and now we're doing one on Beamey stuff.

00:01:21.420 Beamey.

00:01:22.520 You know?

00:01:22.960 um so I am curious Mike what kind of role would you say the BMI has played in your life like how

00:01:32.560 does it show up for you oh man I mean as like a guy who sort of presents as like quote-unquote

00:01:39.020 normal on the BMI I think it like doesn't play much of a role at all like I actually went to

00:01:44.100 the doctor's office a couple of months ago and they asked to weigh me and I was like oh I prefer

00:01:48.120 not to be weighed and i was ready to like have a big fight about it be like this is ridiculous it's

00:01:53.240 not related to health blah blah blah and they were like okay yeah hopefully that means that like

00:01:57.460 doctor's offices are becoming more chill about this but i think it also means that like he's a

00:02:01.100 thin guy and we don't need to weigh him like i think that's obviously playing into it too right

00:02:05.800 it only applies to bodies that we sort of deem deviant in their size absolutely and then we start

00:02:11.520 to care yep and then we start to care and that uh applies to underweight people and it applies

00:02:16.200 really, really prominently to people who are quote unquote overweight.

00:02:19.860 I hope we mostly focus on skinny shaming in this episode.

00:02:22.660 I think somebody has to.

00:02:23.620 You know, it's my wheelhouse, Mike.

00:02:25.360 I know, you love it.

00:02:26.360 It's your number one issue.

00:02:28.400 So the BMI is a simple calculation.

00:02:31.800 It is your weight in kilograms divided by your height in meters squared.

00:02:37.760 It doesn't measure muscle mass or body fat or build or age or anything else.

00:02:42.960 it is truly just like your weight divided by your height, the end. And in many sort of medical

00:02:49.680 systems around the country and around the world, it has become central to accessing medical care.

00:02:55.020 And as we will learn today, its history is absolutely not as a tried and true medical tool.

00:03:02.980 Shocking twist. I've spent the last couple of weeks actually reading a bunch of books about

00:03:06.520 race and IQ and like this whole like nightmare of an academic field. And I don't know much about

00:03:12.580 the history of the BMI, but I do think that basically any scientific effort to boil a

00:03:18.560 complex phenomenon such as health or intelligence down to one number is just like pre-doomed. Like

00:03:26.600 it's just always a bad idea. Well, and it's always a bad idea to try and boil all that stuff down

00:03:33.220 into one measure. And it's an extra fucking bad idea when we only ever put white people in charge 0.98

00:03:39.320 because what happens with the BMI, what happens with IQ tests, all of that stuff that sort of 0.98

00:03:46.560 came to be in the 1800s and early 1900s is that whether or not they said that that was what they

00:03:52.800 were doing, what white people were functionally doing is looking for reasons to prove that we

00:03:56.580 were like, quote unquote, genetically superior. Yes, I do think that if you come up with a system

00:04:01.800 of ranking humans on like their inherent worth and you end up on the top of it we just need to

00:04:09.380 have a little bit more skepticism of any system that has that output like it's like me coming up

00:04:14.880 with some sort of system of ranking like how good all the names are in america like people named

00:04:19.440 jeff suck and people named david are just trash and like whoops people named mike are just great

00:04:24.280 i came up with this objective system and everybody named mike is cool you'd be like 0.98

00:04:28.880 Mike I don't know right sorry guys I don't make the rules I just absolutely make the rules all

00:04:35.800 we're doing is science here guys oopsie daisy yeah that's right that's right so I actually

00:04:42.540 wrote about the history of the BMI a couple years ago you and I've talked about this piece yeah I

00:04:46.760 love the piece part of what's happened with that piece is that it's gotten very popular which is

00:04:50.220 wonderful but it's also gone through the giant game of telephone that is the internet oh no so

00:04:55.980 when people talk about that piece now they're like the inventor of the bmi was the head of the 0.53

00:05:00.480 eugenics movement and i'm like no he for sure wasn't right that like people are sort of like

00:05:05.280 so incensed at the history which totally makes sense that they start to ascribe intent to the

00:05:12.060 history yeah that as we'll talk about just isn't really documented that doesn't mean it wasn't

00:05:16.560 there but it isn't really documented anywhere and i actually think it's much more interesting

00:05:21.760 and telling that what we have is a history full of people who didn't think they were doing anything

00:05:27.300 discriminatory and created like one of the wildest, worst, and most ubiquitous pieces of science that

00:05:33.620 we all hear about all the time. And also that can sound like a defense, like they were doing their

00:05:39.360 best, but it's like, if you want to prevent this from happening in the future, you do have to

00:05:43.840 actually understand like how it happened and like getting into the nuances of it. Totally. And you

00:05:49.260 and I are both white people right who sort of like think and talk about race in the course of

00:05:53.660 our work and I think it's a really meaningful and instructive thing to look at this history where

00:05:59.780 again all of these white people thought they were helping I think it's it feels much more

00:06:05.440 instructive to me as a white person to go you know what even when I think I'm helping I might

00:06:10.100 be hurting yeah exactly well should we dive on in let's do it okay so our story begins in Ghent

00:06:16.760 in 1796. So we're in Belgium before it was Belgium. In 1796 in Ghent, this guy was born

00:06:23.540 who was named Adolf Kötle. Not a lot of Adolfs running around these days. He was not a healthcare

00:06:30.460 provider of any kind, not a medical researcher of any kind. His work otherwise did not revolve

00:06:36.480 around the human body at all. It revolved way more around astronomy and around statistics

00:06:43.260 and around analyzing state data and he's a guy who's very interested in describing the world

00:06:51.380 as it is he wants to figure out why the world works the way that it is and articulate that

00:06:57.140 this is like chekhov's scientist you're like establishing that this guy's like not trying to

00:07:02.940 do any harm he's interested in like describing the world and like maybe coming up with some

00:07:07.300 like measurement systems mike i just really appreciate that anytime i try to like structure

00:07:12.480 a twist into a story. You're like, no, I can tell what you're doing.

00:07:17.740 The good guy scientist doing his best. I wonder what will happen.

00:07:21.180 I mean, I think more than anything, he's described as a bureaucrat and a sort of

00:07:26.580 population analysis kind of guy. It is worth noting that his work happens against the backdrop

00:07:33.700 of a major civil war that becomes the Belgian revolution. And what he wants to do while

00:07:40.960 belgium is sort of uh working toward its independence is to put belgium on the intellectual

00:07:47.140 map there's this sense amongst belgian academics that the enlightenment happened and sort of passed

00:07:52.420 them by and so could they kind of decides that he's gonna be the guy never underestimate the

00:07:59.220 importance of like dude insecurities yeah maybe going a little too fast and like cutting some

00:08:05.600 corners. So he starts working on these really big swings kind of academically. His biggest project

00:08:14.340 is something that he calls social physics. Is this something that you've heard about at all,

00:08:18.520 Mike? Social physics? No. He's essentially looking at data sets and analyzing data sets about people

00:08:26.100 and is trying to look for sort of social quote unquote laws that kind of mimic the laws of

00:08:32.340 physics so something like if you eat off of smaller plates you'll eat 30 less watertight

00:08:38.400 his findings are actually better than brian okay okay not saying much but you know so he writes

00:08:45.420 quite a bit at this time about he wants to figure out how to measure acts of like courage and

00:08:49.960 heroism he wants to measure acts of cowardice and malice and all of these different things

00:08:56.700 but he's like one dude and how the fuck do you measure courage yeah at a population level right

00:09:03.700 so he doesn't have the infrastructure to pull all that off so he starts analyzing state gathered

00:09:08.380 data sets and those are things that are way more boring frankly like birth rates and death rates

00:09:13.820 and marriages and height and weight as it turns out this was all part for him of finding his

00:09:21.380 idealized kind of average man right that average man was defined mathematically absolutely as sort

00:09:27.700 of like the center of a bell curve no question but it was also an ideal right in his mind the

00:09:34.960 average was what everyone should aspire to and we should have more sort of homogeneity we should

00:09:40.580 have more sort of like aspiring to normalcy he actually says at one point quote if the average

00:09:48.080 man were completely determined, we might consider him as the type of perfection and everything

00:09:54.060 differing from his proportion or condition would constitute deformity or disease or monstrosity.

00:10:00.700 So what's like the output of this?

00:10:02.360 So he finds stuff like death rates are highest in February.

00:10:06.300 He starts looking at birth rates and figuring out when those are highest and lowest and

00:10:09.720 stuff like that.

00:10:10.500 So what he's looking for again is some kind of pattern that's like, aha, here's a secret,

00:10:16.100 you know key to understanding the human condition weird and that is what leads him to creation of

00:10:23.860 what we later come to know as the bmi he's trying to build the case for this idea of social physics

00:10:31.140 the sort of like laws of human behavior kind of stuff and he's using whatever state gathered data

00:10:36.680 he can get his hands on and one of those data sets is height and weight data from france and

00:10:43.580 scotland okay those data sets are made up exclusively of men exclusively of white people

00:10:49.720 he analyzes this data he plots it out he finds a bell curve and this whole process and sort of the

00:10:57.180 output of it is called cutlay's index he envisions the index being used by the state to help predict

00:11:06.140 the size and shape of the population as a whole and he's actually very clear at the time that

00:11:13.400 the BMI is not to be used for individual diagnosis or treatment or assessment. He's like, this is a

00:11:19.980 population level tool. Do not try to use it on individuals. It's not going to work. It doesn't

00:11:24.580 make sense. Right. So he basically has this index of like the average French and Scottish person

00:11:30.520 has like this ratio between their height and their weight. Yeah. It's like plotting out like the

00:11:34.760 average length of people's arms to like their average shoe size. It's like there's a ratio and

00:11:39.920 like it differs between people, whatever. Totally. And this was sort of like a footnote

00:11:43.940 in his work around social physics at the time. It was not the main event. And it was his work did

00:11:49.640 generate controversy and did generate interest and debate. But it was not about the BMI. It was

00:11:56.280 about social physics. A bunch of his contemporaries were like, I don't like this because we have free

00:12:01.520 will. Right. So why would there be laws that govern human behavior? We govern human behavior.

00:12:06.560 how dare you i mean in their defense it is a very dumb idea it seems totally asinine 0.85

00:12:13.820 yeah it's not great it's not a worthwhile endeavor the trick here this is where it gets like a little 0.58

00:12:19.940 sticky after he dies his work gets picked up by some pretty unsavory characters so mike i'm gonna

00:12:28.060 i'm gonna ask if you're familiar with a movement called eugenics oh a little bit familiar especially

00:12:36.040 after all my reading last couple weeks. Yeah, totally. I mean, this is the idea that basically 0.94

00:12:40.420 humans are like livestock in that there are some humans that are superior to others. And we can

00:12:45.280 basically like make the human population more superior over time by encouraging breeding among

00:12:51.780 the good ones and discouraging breeding among the bad ones. So eugenics refers to sort of the

00:12:58.820 bettering of the human population over time. And then dysgenics is the opposite, is this idea that 0.55

00:13:04.680 like, human societies are declining because, like, the stupid people and, like, the racial 1.00

00:13:09.360 minorities are procreating more than, like, their social betters is basically the theory, right? 1.00

00:13:15.560 Right. It's, uh, idiocracy. 0.92

00:13:17.620 I feel compelled to point out that, like, this is total fucking nonsense. 1.00

00:13:22.040 Yeah. 0.99

00:13:22.360 Evolution does not happen on these timescales. Like, it's a complete fallacy to think that,

00:13:28.060 like, you know, since the 1950s, higher birth rates among poor people, like, mean anything. 0.98

00:13:33.980 So just like as a scientific endeavor, it's just complete trash. 0.88

00:13:40.400 I mean, I think it also it feels worth mentioning that it wasn't just the discouragement of procreation amongst quote unquote undesirable groups of people.

00:13:49.840 there were many many state apparatuses focused on forced sterilization of people of color of

00:13:58.960 immigrants of autistic people of people with developmental disabilities of sex workers 0.89

00:14:03.740 this is actually where we get the term moron it was an official range of iq scores and if someone 0.99

00:14:11.120 was declared legally to be a moron they would be forcibly sterilized yeah it's really bad i think 0.94

00:14:16.440 Another thing to know about sort of what happens with Kutle's work is that it gets picked up by 0.98

00:14:21.400 this guy, Francis Galton. Is that someone you've come across in your research? No, I don't know.

00:14:27.240 Galton was sort of a leader in scientific racism. He was a major, major vocal proponent of eugenics.

00:14:34.140 He was knighted for his contributions to the eugenics movement. Sir eugenics.

00:14:39.660 That's right. He was also a big believer in social Darwinism, which is perhaps unsurprising

00:14:45.940 because do you want to know who his cousin was? Was it Charles Darwin? Yes, it was.

00:14:50.740 Oh, so Darwin has a problematic cousin, just like everybody else.

00:14:53.800 Totally. So there is a quote from Canada's eugenics archive, where they sort of point

00:15:01.460 out Ketle and Galton as key figures in this. And they essentially say that Ketle was looking for

00:15:07.740 the average and labeled the average ideal. But Galton really took it to the next level. So here's

00:15:12.940 what they say about that quote it was galton who while building upon cutlay's notion of the quote

00:15:18.680 unquote average man a product of measurements and statistics affected an important twist

00:15:23.900 instead of positing the normal as healthy and desirable galton equated the normal with the

00:15:29.820 mediocre oh within this tradition the normal state is to be transcended improved upon and overcome

00:15:37.120 sure right they're all just making stuff up without realizing that they're making stuff up

00:15:41.120 yeah it's all totally fucking made up because it's not it's not clear that the average should

00:15:45.420 be the ideal either that's right but it's also not clear that the average should be bad like 0.88

00:15:49.200 they're they're just like putting value judgments into this and calling it science i mean they do

00:15:53.300 this again so like cutlay is also credited with uh founding what's been what was later sort of 0.96

00:15:58.820 called the positivist school of criminology that's where we get shit like homo criminalis 0.77

00:16:06.060 is this something you're familiar with mike dude this comes up a lot in the race and iq 0.94

00:16:10.320 literature tell me this is the idea that there are actual physical features of criminals like

00:16:15.680 inborn criminals and so what i found out reading stephen j gould's the mismeasure of man

00:16:20.540 is that count dracula in that book was specifically written to have the facial features of the born

00:16:27.800 criminal what yes so like the high widow's peak the long nose like the sharp cheekbones all of

00:16:34.900 that was at the time considered to be the sort of the criminological features and there was also 0.71

00:16:40.520 this weird science about how born criminals don't blush this is complete junk science but this is

00:16:48.220 one of the things of like oh he doesn't blush he must be a criminal and like part of that might be 0.81

00:16:53.060 wrapped up in dracula like being sort of you know cold-blooded or whatever well also part of that is

00:16:58.320 like such a measure of white people yes exactly yes like i'm constitutionally incapable of committing

00:17:04.260 a crime because all i do is blush try again jokers like it's not great it's not great i mean

00:17:10.080 this is like one branch off of cutlay's work is sort of being sort of used as a justification for

00:17:17.400 for eugenics so how how is the bmi related to all of this these forced sterilizations are they being

00:17:23.660 done on a bmi basis not that i found but it is this idea that is sort of like a wave that is

00:17:29.160 started by Cutlay, which is the idea of like, what does a normal person look like gets immediately

00:17:35.940 transferred over within a couple of decades of his death into if we can know what normal looks

00:17:41.420 like, we can know what exceptional looks like, and we can only be exceptional people. And that

00:17:45.060 means white and wealthy and not disabled and all of these sorts of things, right? This project of

00:17:50.600 social physics sort of starts to inform all kinds of systems in a way that is disconnected from what

00:17:57.240 he thought it was going to do, right? So BMI isn't like officially a justification for eugenics,

00:18:03.080 but eugenics is like the context in which the BMI is gaining more notice. Absolutely. The other

00:18:09.360 context in which it's gaining more notice is through insurance companies. Oh, right. So in

00:18:17.300 1842, Kudle creates Kudle's index, later called the BMI. By 1867, so still within his lifetime,

00:18:25.480 the first American life insurance company creates height and weight tables for the purposes of

00:18:33.020 charging fat policyholders more. Interesting. Again, like this is like 25 years after Kudle

00:18:39.140 creates the BMI. This idea of like a quote unquote normalized body starts to be used for

00:18:46.060 corporate profit, which will be a through line in this story. A bunch of different insurance

00:18:51.520 companies create a bunch of different tables, and then the sort of industry as a whole realizes that

00:18:56.840 they should probably standardize them. The first sort of newly aligned insurance table that's used

00:19:04.860 by multiple companies is the MetLife table, which was introduced in 1942. So it really does take

00:19:11.900 them quite a bit of time to get there. So this whole time, they're using Cutlay's data on French

00:19:17.480 and scottish people like that's still the measurement that they're using no no no they

00:19:21.480 are making up their own measurements oh they have taken the idea that there is a correct weight for

00:19:28.220 people to be and they're like we think it's this right so each different insurance company is fully

00:19:34.500 making up what they think the correct weight is sometimes they are broken out by age sometimes

00:19:40.620 they're broken up by gender sometimes they're broken out by um something called frame size

00:19:45.540 So a small frame or a large frame, they don't account for age.

00:19:50.660 They don't account for race or ethnicity or disability or health conditions or any of

00:19:55.780 that kind of stuff.

00:19:56.800 So I might be overweight on the MetLife version, but I might be like normal on the Cutlay version.

00:20:03.580 Yeah, there are some, I looked at some of these charts and there's genuinely like a

00:20:06.560 40 pound difference in some of them.

00:20:09.140 It's really significant differences.

00:20:11.420 the data that they're using here is super duper all over the place like they're drawing their

00:20:17.200 examples from their own pools of policyholders so they're basing all of these charts on the

00:20:22.180 height and weight of people with the wealth and inclination to buy life insurance policies which

00:20:27.000 once again means at this point in 1942 that is white men everybody yeah a bunch of their data

00:20:33.360 is also self-reported some of the weigh-ins that they use for these charts include people like

00:20:39.600 wearing their clothes and shoes and some of them don't like it's a total mess right right that's in

00:20:46.020 the 40s these insurance charts sort of keep kind of floating around some doctors actually start to 0.65

00:20:52.540 use the insurance charts as guidelines for their individual patients which is truly fucking wild

00:20:58.620 to me because again insurance companies are staffed by actuaries they're not staffed by doctors

00:21:04.940 They're not staffed by anyone with sort of health care, individual care provision experience.

00:21:11.220 And it makes its way into doctor's offices enough that there becomes this sort of like

00:21:15.860 desire for a unified system across doctors in the same way that insurance companies have

00:21:21.600 developed a unified system for insurance companies.

00:21:24.380 The person who decides to take on this challenge of finding the standardized system is our

00:21:31.140 old pal Ansel Keys.

00:21:33.000 ah here we go he really was as close as they had at the time to like a celebrity researcher

00:21:40.540 yes he's on the cover of time magazine he's responsible for military k rations he's

00:21:47.800 responsible for the minnesota starvation study he's also a big part of like if you would like

00:21:53.260 to know about the history of the low-fat diet craze go back and listen to our episode on snack

00:21:56.900 well he is like all over that business he has called fatness and fat people disgusting a hazard

00:22:04.880 to health and quote ethically repugnant yeah so sorry for my unethical body everybody in his 0.75

00:22:12.100 infamous newsweek cover story he talks about people like eating themselves to death i spared

00:22:16.660 myself reading that piece for this and now i'm very glad that i did yeah so ancel keys starts

00:22:24.020 looking for ways to effectively measure body fat. He's not looking for the best way to measure and

00:22:31.800 most accurate way to measure body fat. He's looking for the most cost effective way for

00:22:37.840 doctors to do this in their offices and healthcare providers to do this in their offices,

00:22:41.920 which is a different question. And he's also somebody we've established

00:22:45.820 is not a neutral arbiter of this. He's clearly somebody who thinks that fatness is a crisis and

00:22:52.920 fat in the diet is a crisis yes absolutely like those are the two beliefs that he's coming into

00:22:57.440 this project with so he conducts a study of 7 500 men from five different countries so he tests

00:23:05.260 three methods for measuring body fat these are the three sort of most common at the time one is

00:23:13.320 water displacement where they fully just like submerge you in a tank of water and see how much

00:23:18.660 water you've displaced and that's how much body fat you have great another one is skin fold tests

00:23:24.760 which are where they get out those big calipers and measure the skin folds it's better to reserve

00:23:29.620 those for children in front of all of their peers that's that's not let's not do that in doctor's 0.76

00:23:35.100 offices yeah that's right so like cutlay he draws his subjects from predominantly white nations

00:23:45.460 he's drawing subjects from the u.s from finland from italy and he's also drawing them from japan

00:23:51.800 and south africa and he does note this in the study that while he had participation in south

00:23:58.140 africa from bantu men so men for the bantu tribe it was not a representative sample so it's like

00:24:06.160 he's like technically including black people in this study but not using any of the data in his

00:24:10.600 analysis or recommendations but it's basically like it's there but ignore it yeah exactly

00:24:15.440 So once again, he's like centering white people. He's centering wealth. And it's only men, only men. He is sort of pretty circumspect about his findings in this actual study. He says, quote, again, the body mass index proves to be, if not fully satisfactory, at least as good as any other relative weight index as an indicator of relative obesity.

00:24:38.180 still if density is truly and closely inversely proportional to body fatness not more than half

00:24:45.420 of the total variance of body fatness is accounted for by the regression of fatness on the body mass

00:24:50.300 index so basically what he's saying is the bmi is the strongest of three weak and imperfect

00:24:57.900 measures and it's right about half of the time because like the other methods if you're putting

00:25:03.120 somebody into a bathtub and figuring out how much water they displace that's just measuring like how

00:25:07.740 big they are yeah so like they might be like a super duper buff person right the rock so like

00:25:14.000 they're all pretty bad totally i mean i think again as we're looking at sort of like this

00:25:19.280 understanding of the bmi as some kind of like hard and fast medical truth this is happening

00:25:24.540 in the 70s we are in the last 50 years right right when this really gets sort of introduced

00:25:30.420 as an individual medical diagnostic tool, right?

00:25:35.200 It just is fascinating to me that like,

00:25:37.460 it's right about half of the time.

00:25:38.940 So it's the best we've got.

00:25:40.080 So let's run with it.

00:25:41.140 It's also worth noting that those numbers hold fast.

00:25:43.420 Like there was a study in 2011 that found the same thing.

00:25:46.960 It predicts obesity about half the time.

00:25:49.280 There's also this thing where I feel like a lot of these

00:25:52.040 kind of methodologies, people will write papers

00:25:55.520 documenting them and like proposing these as methodologies

00:25:58.080 and being like well obviously there's weaknesses and obviously like no one's gonna run with this

00:26:03.700 yeah totally and then it's like surprise yeah it's like uh no one's gonna use this for individuals

00:26:09.500 clearly and then people see it and they're like a number yeah let's use that totally i like this

00:26:15.720 one there's a chart yes and like all of these caveats get completely erased totally so within

00:26:22.880 a few years of this finding from keys the national institutes of health in the u.s

00:26:29.200 has a conference on the quote-unquote health implications of obesity right we've now got

00:26:36.640 the bmi it's been sort of anointed in like the least dramatic way right as like the the least

00:26:44.480 worst measure of fatness and the nih goes great we actually have to have a conversation about this

00:26:50.900 at a population level, right? And they hold this conference that's designed to set medical

00:26:58.660 categories for fatness. So this is where we actually get categories that are sort of being

00:27:05.360 refined around who is quote unquote overweight, who is quote unquote severe overweight, who is

00:27:11.560 quote unquote obese and who is quote unquote severe obese. Oh, so right now we don't have

00:27:16.080 cutoffs we don't have the 20 to 25 thing yet not yet okay basically like what we're about to talk

00:27:21.860 about is a solid 30 years of those categories being redefined and renegotiated every like

00:27:29.820 five or ten years by the u.s government oh wow the way that we talk about quote-unquote being

00:27:36.040 overweight or obese now is we assume that that is tied to some level of like the onset of health

00:27:43.820 complications or the increased risk of contracting certain diseases or whatever the way that they

00:27:51.680 defined the nih defined them was by a percentile of the population oh wow so it's just like you're

00:27:58.480 fatter than 90 of americans but there's no connection with like you're 18 more likely to

00:28:05.000 have cardiovascular disease or like none of that stuff is included yet none of that stuff is

00:28:09.480 included this nih definition from the 70s says that overweight people are anyone in the 85th

00:28:17.400 percentile or above in terms of their weight in the late 70s okay so that's a bmi of 27.8 for men

00:28:26.440 and 27.3 for women wait reverse bmi look up here's a bmi calculator all right let's say

00:28:37.420 five foot ten let's pretend i'm as tall as i am on my tinder profile uh and it was 27.5 for men

00:28:45.600 it's 27.8 27.8 okay so if i'm a 5 10 dude if i weigh more than 194 pounds i'm i guess overweight

00:28:58.100 like what's the what's the category yeah that's overweight that's the start of being too fat

00:29:03.240 okay severe overweight is the 95th percentile it's the bmi of the 95th percentile okay and then

00:29:09.880 they have a separate scale of measures for obesity and severe obesity both of those are

00:29:16.180 tested by skin fold thickness instead of bmi okay so once you get to a certain size then they switch

00:29:21.900 to skin fold not even once you get like someone could be overweight but not obese or obese but

00:29:28.100 not overweight oh because they're using totally different measures oh weird so like calipers 0.97

00:29:32.980 It's so fucking weird, dude. Yeah. I think it's also worth noting that like the cutoff for 0.96

00:29:37.360 overweight in the seventies is 27.8 for men. The cutoff for overweight today is 25 for people of

00:29:46.820 all genders. Wait, 20. All right, here we go. 25. I'm a five foot 10 dude. So I used to be able to

00:29:52.940 weigh 194 pounds before I'm overweight. Now I can only weigh 174 pounds before I'm overweight.

00:29:59.100 Right. So it's a 20 pound difference just by the definitions that we use. Right. These are really significant changes. We're in this moment where ideal weights, quote unquote, are fully being invented. And there are people in a room going, I think this is too fat. No, I think this is too fat. And again, they're being defined not relative to health risks, but relative to other people.

00:30:22.880 right so it's basically like the biggest americans like must be at higher health risk it's not there's

00:30:28.280 no diversity within that group that's right it is the largest americans must be at the greatest

00:30:33.080 health risk and they are because i don't like that they're so right right what happens is that in

00:30:38.920 1985 the national institutes of health revised their definitions of obesity to also be tied to 0.77

00:30:44.800 the bmi so they pull out the skin calipers thing and they're like okay it's all bmi now okay at 0.74

00:30:49.480 least it's consistently trash. And that's when we really get like BMI becomes the measure. 0.98

00:30:58.660 Because by 1990, we're fully in the obesity panic mode. That's when we've already had this wave of

00:31:05.180 articles coming out about like the future of our children and our national defense and all this,

00:31:09.820 like the population is pretty well briefed by the early 90s.

00:31:12.660 Yes, but we're not yet in obesity epidemic mode.

00:31:17.380 Oh, is that later?

00:31:18.300 That happens in 1995. And this is the thing I am constitutionally incapable of shutting up about

00:31:26.500 at this point. In 1995, the World Health Organization decides that the BMI is going

00:31:32.320 to be their new global standard for measuring overweight and obesity. That's bad. As part of

00:31:39.860 that decision, they do a couple of things that are very, very, very controversial amongst

00:31:47.460 researchers and medical care providers one they decide to use start using the bmi in children oh

00:31:56.180 what yeah so prior to this the bmi has been a measure for adults there is quite a bit of back

00:32:03.960 and forth at this time amongst pediatricians and pediatric researchers going it really does not

00:32:11.400 make sense to try and tie weight to height for children because essentially what happens in

00:32:18.580 children's growth processes is they grow out and then they grow up and they grow out and then they

00:32:22.640 grow up right like childhood and adolescence are a wild time to try and standardize bodies

00:32:29.000 we also don't have data on you know kids with a bmi of 26.4 at age 10 are 2.1 times more likely

00:32:39.300 to have cardiovascular disease at age 50. 0.97

00:32:41.760 It's so fucking noisy to even try to get that kind of data. 0.96

00:32:45.620 Because when we're talking about things like lifestyle diseases, right, of like diabetes 0.96

00:32:49.000 and cardiovascular disease, that stuff takes decades to happen.

00:32:53.080 Yes.

00:32:53.460 And like people's weights fluctuate wildly throughout the course of their life.

00:32:57.920 So a kid who's like fat at, you know, seven, you would need some like pretty robust data

00:33:03.200 to show that that puts him at a higher risk of being unhealthy later.

00:33:06.920 Like you really have to prove that.

00:33:08.840 Mike, I'm about to blow your mind.

00:33:10.960 They did not have any of that data.

00:33:12.500 They did not have the data.

00:33:15.180 Wow.

00:33:17.380 So basically what they decide to do, they sort of track growth studies from Brazil,

00:33:24.540 from Great Britain, from Hong Kong, from the Netherlands, Singapore, and the US.

00:33:29.540 And they sort of decide that what they're going to do is just extend the curve of the

00:33:35.420 BMI for adults.

00:33:37.060 Oh, just like draw the line? 0.99

00:33:38.280 like just keep drawing the line down yes that's all they're doing and they're like this is for

00:33:43.140 kids now oh i always love whenever i hear the phrase like if current trends continue yeah it's

00:33:50.040 always like if current trends continue like 60 of the population will be obese in like 2024 or

00:33:55.160 whatever and it's like okay but if current trends continue 112 of the population will be obese by

00:34:01.640 like 2030 yes if we're drawing trend lines then they're going to exceed 100 at some point so we

00:34:06.820 can't draw the trend lines in straight lines because that's not how trends work.

00:34:10.320 That's right. The other thing that they do is that they get recommendations from WHO staff

00:34:17.220 saying, actually, our evidence shows that people can be healthy at higher weights. So you should

00:34:23.060 probably actually raise the floor for who's considered overweight and who's considered

00:34:27.760 obese. So people are already sounding the alarm about this. They're already saying,

00:34:31.580 I don't think this measure is right. And actually, if we're going to adopt this as an international

00:34:35.160 standard, we should probably say that overweight starts at a BMI of like 30 or 28 or something,

00:34:40.680 right? Like quite a bit higher than it is now. In both cases, they do the opposite of what is

00:34:45.840 recommended to them by healthcare practitioners, right? And a bunch more people are now going to

00:34:50.840 be considered medically overweight and medically obese, right? So in 1995, the WHO changes their

00:34:57.980 definitions of who is and who is not quote unquote overweight or obese and in 1998 the u.s

00:35:04.820 follows suit and comes into alignment with those international measures and that's how it's

00:35:10.480 reported is like uh america was out of step with international guidelines now we're in step with

00:35:16.100 international guidelines and whoa we got a lot of fat people oh cnn at the time has one of my

00:35:21.220 favorite leads ever, which is, quote, millions of Americans became fat Wednesday, even if they

00:35:28.280 didn't gain a pound. Nice. So that sentence goes on to say, quote, as the federal government

00:35:33.260 adopted a controversial method for determining who is considered overweight. So like, how was

00:35:38.900 your week? I became fat. Yeah, that's right. And what happens is because we've now changed

00:35:45.300 the standards, because it looks like there is an epidemic happening now that wasn't there before,

00:35:50.600 it opens the floodgates for all of this research to be like why is it terrible to be fat right so 0.71

00:35:57.520 we were talking earlier about like the research question of a bunch of these white dudes in the

00:36:01.400 1800s was like i know i'm superior to black people but why right and essentially the research that we

00:36:06.780 get here is we know it's terrible and unhealthy to be fat but why right not like what how do health 0.58

00:36:13.640 measures play out for fat people there's no neutrality in these questions right they are 0.96

00:36:18.480 just like how do we prove what we all already know which is that fat people are hideous and 0.83

00:36:22.560 they're gonna die right like oh no and what's frustrating about this is that there is very

00:36:27.620 consistent data that at a population level people with higher bmis have worse health outcomes so

00:36:34.320 like that's a real correlation but there are things that correlate much better with health

00:36:39.260 outcomes that like we haven't put as much focus on that's right the correlation between like does

00:36:43.920 this person get 30 minutes of exercise five days a week is like a better predictor of bad health

00:36:50.180 regardless of somebody's weight. So it's it's frustrating that like we had this panic over

00:36:55.020 like what people look like and how we can extrapolate that as a proxy indicator when

00:36:59.360 like we could have been framing all of these like diet related disease issues in like a much more

00:37:04.940 accurate way. The thing that I got stuck on this is like kind of a perfect segue. Why the fuck was

00:37:10.820 this the thing yes i get that we're biased against fat people i get that people have been like grossed 0.98

00:37:15.920 out by fat people or whatever for a long time but like why did this in particular become not just a

00:37:21.860 national but an international health policy priority and i found an answer that makes me feel 0.97

00:37:29.800 like i need to wear a fucking tinfoil hat smoking gun i want it i want it so bad i fully like i have 0.94

00:37:37.700 the bulletin board full of like news clippings with like red string and pins and the whole thing 0.98

00:37:43.960 wait is it is it gonna be like hillary clinton like trafficked a bunch of children and like

00:37:49.420 i'm nervous now aubrey it all starts at cosmic ping pong yeah no where are we going now

00:37:55.520 no we're not getting into pizzagate territory thank christ no we're getting into something

00:38:00.820 that is like the answer is hiding in plain sight okay and it also makes me feel like i am losing

00:38:05.620 my grip on reality because it feels so conspiratorial. I'm going to send you this

00:38:10.320 quote. This is what the British Medical Journal has to say about the International Obesity Task

00:38:17.360 Force, which is the sort of body in the WHO that has set these international standards.

00:38:24.580 This quote that you just sent me, it just says, 0.58

00:38:26.540 Killary stole the election from Donald Trump. 1.00

00:38:30.280 Lock her up. Lock her up. 1.00

00:38:32.700 Where are we going with this?

00:38:33.760 No. Okay. The most recent annual report of the newly merged group highlights close ties with WHO, but also shows that two drug companies, Roche and Abbott, are primary sponsors, supplying around two-thirds of its total funding.

00:38:48.600 Roche makes the anti-obesity drug Orlistat, and Abbott makes sibutramine hydrochloride, known as reductil. These sound fake.

00:38:57.600 A senior member of the merged group who has seen funding documents but did not want to be identified told the BMJ that over recent years, sponsorship from drug companies is likely to have amounted to millions.

00:39:10.280 I see where you're going with this.

00:39:12.100 Do you see where I'm going with this?

00:39:13.740 It was Pfizer all along.

00:39:15.380 Like it was these drug companies that want to sell us anti-obesity drugs.

00:39:19.180 So what this quote leaves out is that Reductal, which was sold in the U.S. as Meridia, was in the approval process.

00:39:29.080 Both of these drug companies have weight loss drugs that are in the approval process in the mid to late 90s.

00:39:36.680 But first, they need to establish that weight loss is a going concern for medicine.

00:39:42.400 Right. 0.61

00:39:42.880 And that a fuck ton of people need medical intervention to lose weight.

00:39:48.100 So what they are doing is they are establishing this as a medical concern at sort of a new level and they are lowering these thresholds for what it means to be overweight and obese so you can weigh the same amount and previously be at a quote unquote normal weight and now be overweight or obese.

00:40:08.140 And that is so that Roche and Abbott have customers to buy Meridia and Ally was Orlistat in the U.S.

00:40:19.640 Is that because there were BMI cutoffs for doctors being able to prescribe these?

00:40:24.360 Being able to prescribe them and for insurance to cover them.

00:40:26.760 Ah, right. Yeah. So it's like only over BMI 27.5 can you get this reimbursed.

00:40:32.060 Right. Only the overweight and obese categories qualify for these medical interventions.

00:40:37.180 and if you can lower the threshold of who's considered if you can make more people quote

00:40:42.500 unquote medically overweight or medically obese then you have a fuck ton more customers not only

00:40:48.440 on an individual level but you've got state contracts to handle the obesity epidemic you've

00:40:54.380 got large scale insurance like sweetheart deals with insurance companies who will pay you untold

00:40:59.800 amounts for untold numbers of people who now believe that they are overweight or obese because

00:41:06.000 their doctors are telling them that. So why would they not believe it? Right?

00:41:09.460 I mean, this is a little tinfoil hat. It is a little fucking tinfoil hat. I kept looking for 1.00

00:41:16.140 alternative narratives of how this happened. I was like, I wonder what Rosh and Abbott have to say

00:41:21.760 about how this happened. I wonder what, you know what I mean? Like different sort of entities

00:41:25.320 involved in this have to say there is no alternate narrative. This is the story of how this happened.

00:41:31.820 There's also just the fundamental fact that any other solution to the quote-unquote obesity epidemic, you know, bike lanes to school or, like, subsidies for healthy food or, like, higher food stamps or all of these sort of real solutions to diet-related disease require, like, political tradeoffs and, like, they cost money. 0.65

00:41:52.440 There's no sort of free lunch the way that there is with fucking throwing pharmaceuticals at something.

00:41:58.620 Like, whether or not this is like a deliberate kind of conspiracy by the drug companies and like the government officials or whatever, it's just a lot fucking easier. 0.97

00:42:08.920 That's right. And I also think like, look, it's possible that the WHO is like, we got to get to this overweight and obesity thing at some point.

00:42:15.100 We don't know how we're going to fund it. And the drug companies sort of swoop in and go, what if we funded it?

00:42:20.100 Right. Like there are a bunch of different ways that this could happen. But the fucking fact of the matter is most of the budget of this international task force that's focused on defining who is and who is not overweight and obese is funded by drug companies that absolutely have a stake in this outcome.

00:42:37.240 It doesn't it doesn't look good. It doesn't look good. That's exactly right. It doesn't look good. Whether or not you believe that that is like they're like wringing their hands and they're conspiratorially like hatching a plan behind, you know, in smoke filled rooms or whatever. Or whether you think the WHO wanted and needed to do a thing and drug companies altruistically agreed to fund it. 0.98

00:42:57.920 which like no which no which probably not let's get back to just like documented facts that we can

00:43:03.440 for sure prove regardless of intent right 1995 the who changes their definitions of overweight

00:43:10.240 and obese 1998 the national institute of health in the u.s falls in line those changes are funded

00:43:17.920 by abbott and roche and in 1998 and 1999 both of those companies have weight loss drugs approved

00:43:25.580 by the FDA. Like it's like the next two fucking years. And what we know from our Fen Fen episode 0.98

00:43:32.840 is this is after a decades long drought of a proven weight loss drugs, right? So it is absolutely in

00:43:39.260 their financial best interest to establish that there are more customers who need their product.

00:43:45.620 Right. There's also a way that I think journalistic bias operates. Like if I'm

00:43:51.280 writing an article about a school shooting, I can find experts that will say like it's mental

00:43:56.740 health, like America doesn't have mental health treatment. And I can find experts that say it's

00:44:01.300 guns. We have too many guns. And like the bias in that article isn't necessarily in like what the

00:44:07.380 experts say or even in what I write in the actual text of the article. The bias comes in which

00:44:13.340 experts am I consulting? Yeah, that's right. And that's a very invisible form of bias because

00:44:17.500 there's an infinite number of experts who i could consult on something as broad as that issue and i

00:44:23.940 think as a guy who like worked in international development for 11 years and like i worked on

00:44:28.860 corporate human rights violations like that was the bulk of my human rights career and like i have

00:44:33.740 seen the ways that corporations warp the kinds of human rights issues that get talked about

00:44:40.260 and it is a lot of like which expert is going to be on the panel yeah and like who is going to be

00:44:46.380 pointed to this thing. Yeah. And I can absolutely see that happening here. Another way that that

00:44:51.060 sort of like bias in the populace is promulgated through media, even without intent, is that when

00:44:58.480 we see reporting about the quote unquote obesity epidemic, this entire history is nowhere. Yeah.

00:45:05.500 Yeah. Yeah. Yeah. There is no discussion of like, actually, we spent like a really long time

00:45:10.760 defining and redefining and sort of moving the goalposts. Right. There's no discussion of like,

00:45:15.760 you could have been at a quote-unquote healthy weight in the 70s stayed the same size and now

00:45:20.980 be overweight yeah that's not an indictment of reporters doing that reporting necessarily

00:45:27.420 but it does you can see how when you make that history invisible to people it really seems like

00:45:34.360 there is a very real threat out there it feels a little bit you know what it feels like to me is

00:45:37.980 um we've got all these movies about shark attacks and then you talk to shark experts and they're

00:45:42.720 Like, they pretty much never happen.

00:45:45.000 Yeah.

00:45:45.560 But everyone's freaked out about them all the time.

00:45:47.960 Like, we're being trained to see this as a function of the natural world, not something that is a function of humans' interpretations of other humans.

00:45:57.740 Right.

00:45:58.180 And this completely arbitrary scale that was essentially arbitrary for, like, more than 100 years.

00:46:03.340 And then we kind of backfilled the science because we had already agreed on this one number as, like, the thing that had to be the center of our understanding of hell.

00:46:11.580 That's right.

00:46:11.980 So even when we're talking about these definition changes in like the late 90s, which is so fucking recent, there is also continuing research that's coming out in the last 10 or 15 years that are adding even more complexity and nuance to our understanding about sort of the relationship between weight and health, right?

00:46:33.440 So in 2015, researchers at Harvard and the University of Sheffield release a study where

00:46:40.240 they say they found six different types of obesity, each of which have their own sort

00:46:45.660 of etiology.

00:46:46.840 Just a couple of years later, researchers at Massachusetts General Hospital say that

00:46:51.020 they have observed 59 different types of obesity.

00:46:54.960 So we're trying to sort of cram all of these different potential threads rather than looking

00:47:01.280 closer at like wait a minute what's actually going on here right instead we go oh my god it's even

00:47:06.960 worse than we thought fat people are terrible and also for my sort of years ago research into bmi

00:47:13.160 stuff there also is like very different data based on race yeah the correlation between disease and

00:47:19.900 bmi starts to show up at lower bmis for asian people although there's huge diversity within

00:47:24.700 asia obviously but then for black people like black people can be larger before those correlations

00:47:30.140 start to show up and like again it's all like there's other things that are more correlated

00:47:34.260 like there's no way to talk about this without sounding like kind of like a eugenicist and like

00:47:38.220 shitty yeah but like humans are diverse on like every dimension including like the size that

00:47:42.980 they're kind of best suited to be and so it's not like an academic issue that like this was only 0.94

00:47:50.260 done on white people it's like an actual epidemiological issue we're getting shitty

00:47:55.060 data by applying this to everybody. And it's also been designed pretty much exclusively at this

00:48:02.160 point still for cis men. Yeah, that's weird. It's also so dumb because like women are supposed to

00:48:08.280 have like far more body fat than men. That's right. And there's like no real research on the 1.00

00:48:13.980 impacts of the BMI on trans people. But the BMI is used as a reason to deny trans people surgical

00:48:20.340 care yeah that also plays out now that we're talking about like a global obesity epidemic 0.98

00:48:26.080 quote-unquote there are all of these fucking rankings that come out that are like what are 0.97

00:48:31.860 the fattest countries in the world yeah i hate those would you like to guess at some of the 0.98

00:48:36.380 top 10 fattest countries in the world oh isn't it always like tuvalu and these other like pacific

00:48:41.620 island nations that are like have been large for like most of human history yeah the top 10 is like

00:48:47.860 the cook islands the marshall islands palau tuvalu tonga samoa yeah so like in addition

00:48:54.300 to all of the like garbage science stuff we also now have this like hand wringing about sort of

00:49:00.840 the health of populations that have kind of always been in this size range right right

00:49:06.040 not only that but in the united states our the way that we categorize race and ethnicity

00:49:11.940 lumps together asian and pacific islander communities and like east asian and south

00:49:18.180 asian communities too and east asian and south asian right like yeah asia all of it it's like

00:49:24.000 40 of humanity in like one category totally and if you are sort of looking at race-based differences

00:49:29.520 for how the bmi plays out like the idea that japanese people and samoan people would be in

00:49:34.600 the same category yeah as interpreted like it's just wackadoo like it makes zero sense right

00:49:42.560 and india and china which are not in the top 10 of most quote-unquote obese nations have some of

00:49:50.540 the highest levels of type 2 diabetes diagnoses right so like because we're looking for fat

00:49:55.580 people and the problem of fat people we're also like missing opportunities to intervene on other

00:50:00.160 public health issues right this is also where we sort of like get into some of the pitfalls of

00:50:07.220 sort of conversations that critique the bmi right i think one of the ones that we talked about is

00:50:11.980 like trying to find villains in history right i'm calling myself out with this one is like you can

00:50:17.980 say the rock is obese by the bmi so like that's how you know it's so wrong the implication there

00:50:22.500 is like if it really detected fat people then it would be okay right exactly yeah but the problem

00:50:27.680 with the BMI is that like people who are not fat get lumped in and that's not right. But if it's

00:50:32.180 just fat people, it's fine to have a war on obesity. It's fine to have like all of the shitty 1.00

00:50:36.800 public policy. It's very hard to say both the BMI is trash and it's bad that there aren't like 0.98

00:50:42.880 separate BMIs for like Samoans and Japanese people. Yeah. That's basically like kind of

00:50:48.100 the argument that we're making, but like not really. That's right. I mean, I think like the

00:50:51.520 underlying question here is like, why is it critical to the state, right? Like capital S

00:50:56.860 state to define an ideal weight. Yeah. And the central issue with me is that the BMI and sort

00:51:03.280 of fatness generally has always been presented to us as a proxy indicator, right? Fatness is bad

00:51:09.660 because fatness is an indicator that you are more likely to get heart disease, that you have bad

00:51:13.760 cholesterol, that you have all of these underlying health conditions that we can't see. And because

00:51:18.760 we can't see cardiovascular risk, we use fatness because it's all we have, right? But then what's

00:51:24.880 fucking insane about using the BMI within the medical system is that, like, you can take 0.96

00:51:30.860 people's cholesterol. You can actually ask them, what are your lifestyle factors? What is your 0.95

00:51:36.000 genetic background that puts you at higher risk for heart disease? We're still using a proxy

00:51:41.060 indicator for underlying data when the underlying data is there. Like, if we don't want people to

00:51:47.060 be fat because, like, they might have a bad, like, resting heart rate, like, we can take their 0.99

00:51:50.520 fucking resting heart rate if they're in a doctor's office. And there are interventions 0.99

00:51:53.800 that we know work for those specific things.

00:51:56.320 But instead, we use this proxy

00:51:58.420 as the measure for the health risks.

00:52:00.160 And then we try to control the proxy

00:52:02.980 as a way to control the health risks 0.97

00:52:04.700 rather than just fucking controlling the health risks. 0.66

00:52:07.120 Just controlling the health risks. 0.94

00:52:08.440 Why do we need this intermediate thing?

00:52:11.080 And why have we put all of our effort

00:52:12.600 into this intermediate thing

00:52:13.980 if it's supposed to be the tip of like this health iceberg?

00:52:18.040 Like, let's just look at the iceberg.

00:52:19.540 That's exactly right.

00:52:20.260 I mean, this is one of those places where I'm like,

00:52:22.220 if you want to talk about health, if that's a thing that you want to talk about and you really

00:52:27.260 genuinely care about population level health markers and individual care of individual patients,

00:52:32.480 then the BMI is leading us away from that. Yeah. Yeah. That also traces back to the entire

00:52:38.340 fucking history of the entire fucking thing, which was like a dude who thought he was doing 0.99

00:52:42.780 a population level analysis and then a series of people who grabbed onto it largely for profit 0.99

00:52:48.240 motives right first insurance companies and then drug companies right right so like it does feel

00:52:53.660 really challenging to figure out how to have this conversation and i will say it feels challenging

00:52:58.940 to me as a fat person because i think it's easy for me talking about this to read as a very

00:53:05.780 self-serving set of conclusions yeah i was just going to accuse you of glorifying obesity thank

00:53:10.120 you i'm trying my best that's how all of our episodes end you saw my eyeliner today if that's

00:53:15.540 not glorifying obesity i don't know what is glory b so i mean like i didn't really sleep particularly

00:53:23.200 well last night i was like all churned up about recording this episode oh no way which usually

00:53:28.320 happens like a little bit but not to this level and i think a lot of that has to do with like

00:53:32.440 being a fat person saying into a microphone like here's what i researched and found right yeah

00:53:39.640 about something that is seen as self-serving right like it made me think about like when we had our

00:53:45.220 marriage equality court case in oregon the judge the the circuit court judge who was assigned was 0.98

00:53:51.620 a gay man and there was a big outburst about like he can't be impartial uh for fuck's sake yeah i am 0.96

00:53:57.760 genuinely nervous about how this conversation plays out from here but what's so fascinating 0.98

00:54:02.240 is that like this accusation against you implies that thin people don't have any dog in this fight

00:54:09.440 and that's not true yeah that's right whether you are fat or thin like your body size affects

00:54:14.580 the way that you see the world and the way that you interpret political and social issues.

00:54:19.480 And so thin people also have a reason to think that fatness is bad and to think that you

00:54:26.580 are virtuous for being thin as opposed to like you were born with pretty good genetics

00:54:29.940 or whatever.

00:54:31.080 I also think, I mean, I hate to be the person who's like, well, what about the people with

00:54:35.240 more power?

00:54:36.120 But the BMI is not working for skinny people either.

00:54:39.340 That's right.

00:54:39.760 Because you have people like Bob Harper, the demonic personal trainer who hosts the 0.82

00:54:44.380 biggest loser who like does more exercise than anyone else on planet earth who has a heart

00:54:48.500 attack in his 40s and then goes back to host the biggest loser and it's like and that's why all of 0.96

00:54:54.400 you need to lose weight exactly like there are people who have risks of like lifestyle diseases 0.82

00:55:00.160 and like genetic diseases and we're like well you're thin so i don't need to run those tests

00:55:04.240 for you it's much worse for fat people but it's not working for anybody well and it's much worse

00:55:09.400 for fat people it is arguably the worst of all for fat people who are chronically ill yeah my god

00:55:14.420 because then the response from thin people writ large from fat people who don't have chronic 0.91

00:55:21.100 illnesses and from institutions and like medical systems is well you brought this on yourself you

00:55:26.620 knew the risks you could have controlled your weight and you didn't i do i mean this also this

00:55:30.740 is this is my tinfoil hat turn in the episode oh my god tell me join me i actually think that like

00:55:37.580 we are vastly underestimating the effect of medical bias as a driver of the quote-unquote

00:55:45.000 health effects of obesity yeah i mean this is anecdotal it's really hard to get data eventually

00:55:49.420 we will understand this phenomenon more but like for our show after i wrote my article about obesity 0.88

00:55:55.040 in 2018 our inboxes are jam-packed with people who are like i had a fucking tumor for years 0.94

00:56:02.680 that nobody diagnosed because they kept telling me to lose weight. 0.99

00:56:06.320 Very severe health effects that nobody looks into because it's like, oh, you're fat, so

00:56:11.520 I'm not going to run these tests on you, right?

00:56:13.460 I'm not going to give you an MRI.

00:56:14.880 I'm not going to listen to you.

00:56:16.400 I'm not going to believe you until you lose enough weight that you appear as a person

00:56:21.200 to me.

00:56:22.180 Like I said, there is a correlation between higher BMI and worse health. 0.99

00:56:26.280 And like some percentage of that is also the fact that like life threatening illnesses in fat people do not get fucking diagnosed. 0.82

00:56:35.700 Well, and on top of that, so like 100% the number of horror stories from like individual fat people out in the world. 0.95

00:56:43.100 People do not understand how common this is.

00:56:45.040 People really, really, really don't understand.

00:56:46.900 And it is one of the great fears of my life that I will die of a totally treatable or preventable

00:56:52.020 thing because my doctor can't conceive of me having any other health problem than just being

00:56:57.360 a fat person. Like that is a fear that follows me every time I go into a doctor's office. It's

00:57:02.460 terrible. And two other things that we know for sure, you're right that this is hard to like get

00:57:07.240 good data on this specific like misdiagnosis stuff. But I will say we do know for fucking sure 0.94

00:57:13.340 that there is like a lot of data that says that fat people generally and fat women in particular 0.97

00:57:19.820 postpone care because they know that they are going to be overtly directly judged by their

00:57:26.860 health care providers and they know that they will get substandard care because of that judgment

00:57:31.920 right i've written about this that i went for years without seeing a doctor because i just 0.98

00:57:36.200 knew that it was just going to be another fucking weight loss lecture because i went in for an ear 0.96

00:57:39.740 infection at one point and my aftercare instructions were to lose weight the other 0.97

00:57:43.920 thing that we know for fucking sure is that there's quite a bit of data on when and where 0.85

00:57:47.700 fat people report experiencing weight stigma right number one is friends family and intimate 0.97

00:57:54.040 partners which is real shitty so everybody all of us do a little reflecting that's real bad

00:57:59.020 and number two is health care providers yeah so like it's really tricky to figure out how to talk

00:58:05.400 about medical bias in a way that doesn't seem like anti-doctor too or anti-healthcare provider 0.50

00:58:10.840 that is like, no, I really fucking need what you're offering. And right now I can't actually

00:58:16.020 get it from you. And I would say, you know, when you look at sort of these consistent correlations

00:58:20.960 between like fat people and like lower life expectancy, it strains credulity that a population

00:58:26.960 that systematically does not seek medical care, that that would have nothing to do with their

00:58:33.280 shorter life expectancy like yep that is absurd to say that like oh yeah by the way fat people

00:58:39.080 are like delaying care for years and like we shouldn't be factoring that into our understanding

00:58:45.580 of like the relationship between weight and health like it is nuts to think that it would yeah i mean

00:58:50.000 so the other thing that we do have quite a bit of data on is there is a lot of data and it is

00:58:54.900 straight up self-reported data from many different kinds of health care providers that show things

00:59:01.460 like a majority of nurses and nursing students think that fat people who are admitted to the

00:59:06.600 hospital should forcibly be put on very low calorie diets. Yeah, it's really bad. Every

00:59:11.440 study that looks into this finds like, oh, this other group is also biased against fat people.

00:59:15.920 Right. It's every time someone just asks, it's not even like, let's measure their patient

00:59:21.080 interactions. It's just like, you just go up to like a doctor or a nurse or a physician assistant

00:59:26.980 or whoever and you go, hey, what do you think about fat people? And they're like, oh, that

00:59:30.240 they're lazy and that they're not good at following instructions and that they're probably

00:59:33.100 going to die and that I shouldn't have to treat them. Right. There is also some data that shows 0.92

00:59:37.520 that like any intervention starts to change that. There is one study that shows that like a 15

00:59:43.960 minute video clip shown to medical students decreases their levels of bias against fat

00:59:49.700 individuals. Oh, wow. It is truly like all we have to do here is anything. But right now we're using

00:59:55.600 this system which is the bmi it treats it as if there's a straight line from being fat to being

01:00:02.060 in ill health to being a patient that's not worth caring for right and because we also have this

01:00:08.700 sort of like myth that we're really committed to that your personal weight is 100 in your control

01:00:15.240 100 of the time then we can also infer intent from fat people right that like you're not just

01:00:22.800 seeing someone whose body looks different than you you're looking at someone who's deciding not

01:00:27.040 to be thin all the time so you can decide to do whatever you want including deny them health care

01:00:33.700 including like whatever the things are right so like it's a really tricky challenging conversation

01:00:39.380 to get into without sort of feeling like you're like assailing someone's intent right and it's 0.98

01:00:45.180 really not about those things it really is just like fat people are fucking desperate for decent 0.99

01:00:49.460 health care and we're not getting it. Yeah, exactly. We just don't know how to get anybody's 0.99

01:00:53.400 attention to just be like, can you please just treat me like you would treat a thin patient?

01:00:58.460 It is a weird move for doctors to be like, I had to be mean to this patient. She's unhealthy. 1.00

01:01:05.080 Yeah, it's like, yes, I think it's actually like you should probably listen closer to those

01:01:10.380 patients. Right. Yes. Arguably, the patients who you are perceiving as being unhealthy are the

01:01:16.200 people who need your help the fucking most so can you not be a dick to them so maybe like spend more 0.99

01:01:20.720 time with those patients if they're fat and they're telling you about like their migraine 0.99

01:01:23.760 yeah have i ever told you about hondas no honda is the acronym that is disproportionately used to 0.98

01:01:30.280 describe fat patients and it stands for hypertensive obese non-compliant diabetic alcoholic holy shit 0.98

01:01:41.040 sometimes the a stands for asshole nice okay some health care providers somewhere think that that's 0.99

01:01:47.080 actually an okay way to talk about fat patients and think that they can then provide care in an 0.97

01:01:52.020 unbiased way to that person when they're starting from a place of like i've already decided that

01:01:56.840 you have high blood pressure that you have diabetes and that you're non-compliant that

01:02:01.280 you're i've already decided you're not going to listen to me i love the non-compliant part because

01:02:05.540 it's like he can't even lose weight which fails for 98 of people he can't even do this thing that

01:02:12.780 only like one out of 50 people can do oh he's feeling the thing that everyone fails at yeah

01:02:17.460 fart noise yeah like ridiculous i mean there's like the moral arguments which i feel like don't

01:02:23.140 really work when we're talking about like issues of bias you're not going to get people in their

01:02:27.580 hearts right but the last numbers that i've seen are that one third of quote-unquote obese people

01:02:34.220 like have normal health markers and around 25% of like average weight people don't have normal

01:02:40.720 health markers. Yeah. If you are relying on the BMI, you're basically calling a bunch of fat

01:02:45.220 people unhealthy who aren't. And you're basically calling a bunch of thin people healthy when they

01:02:49.200 aren't. Yeah. Even if you want to keep hating fat people, if your goal is to have a healthier

01:02:53.900 country, you would not be using the BMI. Totally. There's a bunch of really good and interesting

01:02:59.220 health data that i found we'll talk about this next time the idea of the quote-unquote obesity

01:03:04.180 paradox oh yeah is this a phrase that you've heard before isn't this like some fat people

01:03:09.240 are healthy it is and not only that but fat seems to protect some people from some health conditions

01:03:15.340 right so like fat people are more likely to have heart attacks but less likely to die of them oh

01:03:20.440 wow it all gets labeled like the obesity paradox quote-unquote which is just right fat people seem 1.00

01:03:25.900 healthy but that's not possible you're like oh fuck that's like some 18th century medicine shit 0.99

01:03:31.840 where they're like this black person is smart right right like the race paradox it's like no 1.00

01:03:38.380 it's just your whole understanding of this issue is fucking wrong right this woman seems to be able 0.93

01:03:43.240 to do things for herself what right like yeah it's just like completely it's like you are showing 0.99

01:03:49.520 your whole ass yeah and i mean i think the other thing that these conversations all leave out 0.98

01:03:54.660 is that like the jury is still fucking out on a lot of this stuff but we are treating it like it 0.99

01:04:00.820 is hard and fast medical knowledge but if you talk to researchers who are working on this right like

01:04:06.440 evolutionary biologists who are researching this stuff they're like uh actually we just found out

01:04:11.620 that your body adjusts to burn the same number of calories regardless of the amount of activity

01:04:16.220 that you're doing and we don't really know why that happens anyway bye yeah like if you actually

01:04:21.380 talk to the sources of the research that we all seem really secure that we think we know they will

01:04:27.280 tell you that we are wrong right right so like that's the bmi i i i feel like i am losing my

01:04:33.760 grip on reality our next episode is going to be about benghazi isn't it aubrey's going down the

01:04:38.860 rabbit hole i've lost her this is it totally look i'm just saying q makes some good points

01:04:44.580 um yeah so our next episode actually will be about how this these sort of shifts in the bmi

01:04:52.820 paved the way for declaring an obesity epidemic and sort of a policy history behind

01:04:58.720 the obesity epidemic which also is termed sort of the quote-unquote war on obesity

01:05:02.860 right so we'll talk about that next time because boy oh boy there's a lot there yeah there's a lot

01:05:07.340 of there's a lot of meetings in switzerland that we need to talk about can i end this with like a

01:05:11.500 little parable yes please do i would love it one of the things that stuck out to me from all this

01:05:16.100 race and iq stuff that i've been reading is you know the the most famous iq test is called the

01:05:21.100 stanford binet test and alfred binet came up with these ways of like measuring iq through like

01:05:26.500 multiple choice questions and he deliberately came up with this measure as a way to get more

01:05:31.320 attention on like kids who needed it the most oh his goal with coming up with these iq tests was

01:05:36.680 to be like there's probably kids that are like falling behind in school and we don't know about

01:05:40.980 them oh wow and of course like 10 minutes after he comes up with the scale people like let's

01:05:45.700 sterilize the children it of course becomes this runaway train the minute there's like a measurement

01:05:51.540 out there because there's always this drive to quantify things like i think so much of it is

01:05:56.460 like the fact that our country is dominated by men and there's like something sort of that feels

01:06:01.420 valid about a number that doesn't feel valid about like any kind of qualitative measure yeah i really

01:06:08.320 think something similar happened with the BMI, where it's like, this number never really meant

01:06:13.400 very much. And there was always so much diversity, like two people who both have a BMI of like 26.

01:06:20.000 One of them could be super buff. And one of them like might have had an eating disorder before.

01:06:23.800 And like telling her to lose weight is not a fucking great idea. Like, yeah, these numbers 0.93

01:06:27.260 take on this implied scientific rigor that makes us take them far more seriously, and especially

01:06:32.900 makes institutions adopt them much more than they should and takes away all of the nuance.

01:06:38.960 And because we all have like pretty serious implicit biases on a bunch of different measures,

01:06:46.120 we are also pretty incapable of internalizing those measures without using them to justify

01:06:54.140 the people that we already think are superior being superior and the people who we already

01:06:59.220 think are inferior being inferior, right? Yes. We don't do a really good job of taking in

01:07:04.660 research results without turning them into individual mandates, right? Like there was

01:07:10.160 that whole wave of stuff about visceral fat is the fat that's really bad for you. It's like belly

01:07:14.980 fat is worse for your health. And that turned pretty quickly as a fat person into people being

01:07:20.800 like, you have a lot of belly fat. That means you're going to die and you lose weight. And I'm

01:07:24.840 like i can't control where fat accumulates on my body right like this is scientifically useful i'm

01:07:32.660 sure and also on an individual level there's not an instruction that follows from there that's like

01:07:39.000 oh you guys are right i guess i should have a different body shape like i don't know how to

01:07:43.820 do that yeah you're up there and i need you to be an apple yeah it's like not useful advice for

01:07:48.760 people again like sort of talking about like the nuance of this story in this history the failings 0.67

01:07:54.380 of the bmi are mostly failings of humans yeah which makes it really fucking challenging to

01:08:01.080 talk about this stuff when it gets presented as like it's just capital t capital s the science

01:08:06.220 yeah yeah although aubrey people named mike really are better than all that's my firm belief it's

01:08:13.140 science it's objective it's objective science you're like i created a system wherein short 0.83

01:08:18.920 white men are at the top of the pyramid you know what five foot six gay mics 0.95

01:08:22.560 turns out looking at a piece of paper sorry it says here we're the best science yeah 1.00

01:08:48.920 Thank you.

Maintenance Phase - August 03, 2021

The Body Mass Index

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