We’ve just completed our second full-length podcast. It’s called “Is America’s Obesity Epidemic for Real?” It costs $0.00. (The podcast, that is, not the epidemic.) Get it here at iTunes; if you subscribe, all future episodes will be delivered in your sleep. You can also get it here via RSS feed, or listen now (see box at right).
If you are a regular reader of this blog, you could be forgiven for thinking, Geez, when will these guys shut up about fat already? True, we have written on the topic repeatedly, including: an astounding spike in bariatric surgery; the female-male weight gap; a possible connection between plumbing and obesity; the usefulness of posted calorie information in restaurants; whether behavioral nudges like “piano stairs” help keep people trim; and whether it may be time for a fat tax.
The podcast touches on several of these ideas and more, and features quite a few differing voices and views. It opens with four young women in New York who spent a recent Saturday evening consuming five meals, in a row, at five different establishments. To their credit, they walked from place to place, which had to burn a good 100 calories right there.
I tried to talk to Michelle Obama about “Let’s Move,” her new program to fight childhood obesity, but that interview never happened.
I did speak to a very good proxy: Ezekiel Emanuel, the M.D. and bioethicist who advises the White House on healthcare reform. (He is also the older brother of a certain chief of staff named Rahm; the third brother, FWIW, is Ari, who runs the talent agency now known as William Morris Endeavor, with whom I happen to do business.) Ezekiel made a strong case for government intervention in Americans’ eating habits. When I asked, however, if it was time for a cheeseburger tax, he made clear his limitations. “That’s a political question,” he said. “I think you got the wrong Emanuel brother.”
The podcast also explores the degree to which anti-fat sentiment is a moral one, as opposed to medical or economic. You’ll hear a bit from Steve Levitt on the topic, but more directly from Peggy Howell, a fat and proud woman who has a fascinating (and sobering) story to tell about fat discrimination.
I also interviewed my own physician, who specializes in diabetes control (thanks, Dr. Blum!), as well as Brian Wansink, the outspoken author of Mindless Eating, whose extensive research on eating habits — and his stint at the U.S.D.A., helping rebuild the food pyramid — has given him a ton of insight into the topic.
Perhaps the biggest star of the podcast, however, is someone you’d never think would have something useful to say about obesity: a political scientist. He’s Eric Oliver of the University of Chicago. He is the author of a book called Fat Politics: The Real Story Behind America’s Obesity Epidemic, and nearly all his research runs counter to the prevailing wisdom. In a nutshell, he argues that the “epidemic” is an overwrought product of moralism, shady statistics, and perversely misaligned incentives. His most controversial argument is that the causal relationship between weight and maladies like heart disease, cancer, and even diabetes has not been firmly established.
Here’s one exchange with Oliver from the podcast:
SJD: You write that in 2004, the Centers for Disease Control estimated that obesity is killing 400,000 people a year. Right, do I have that right? That obesity is killing 400,000 people a year?
EO: They issued an article that was published in the Journal of the America Medical Association claiming that, yes, obesity was killing 400,000 people a year.
SJD: And you vehemently disagree, correct?
EO: Well, there were a number of problems with this report, one of which is it was based on data that were about 30 years old. Secondly, the report itself made some computational errors that called into question the findings there in the conclusions. Another set of research from a different division of CDC then later issued a report that said, in fact, that number was probably closer to more like 20,000 people a year. And in fact there were just as many people dying from weighing too little as there were from weighing too much.
I hope you enjoy listening to the podcast; I very much enjoyed making it. As always, feedback is welcome, along with topics you’d like to see covered in the future.
STEPHEN J DUBNER: There are a lot of reasons to come to New York City. Like going out to eat. But not everyone eats five meals, back-to-back, all in one evening. We're starting at Big Nick's on the Upper West Side; it's famous for a "sumo burger," 1 full pound of ground beef.
JESSICA: If you're in a new place, best thing to do is to eat everything you can, I think, especially when traveling. You just have to eat everything that you can't get at home. You know?
DUBNER: So it’s a little after four in the afternoon, on a Saturday. So this is your Saturday afternoon, evening, uh, excursion.
JESSICA: Uh-huh! Big Nick’s, for pizza, and apparently a burger, Zabar’s for goodies, uh, French roast for wine, and mussels, and then we’re going to Gray’s Papaya for a hot dog and Magnolia’s for cupcakes.
JESSICA: But we’re walking! We’re walking to all of them.
DUBNER: Have you thought about total calorie count? At the end of the day?
JESSICA: No way!
ANNOUNCER: This is Freakonomics Radio, a new podcast about the hidden side of ... everything. In this episode ... the underbelly of fat, through the eyes of a 280-pound woman, a top White House health-care adviser, and a couple overweight academics. Here's your host, Stephen Dubner.
DUBNER: I was in Chicago last week, and caught up with my friend and "Freakonomics" co-author Steve Levitt. He took me to eat at a restaurant he loves. Charlie Trotter's? Uh uh.
DUBNER: So Levitt where are we here?
STEVEN D LEVITT: Kentucky Fried Chicken, one of my favorite restaurants.
DUBNER: And which Kentucky Fried Chicken are we in?
LEVITT: The one on Garfield Boulevard, kind of in a rough neighborhood near the University of Chicago,
DUBNER: South side of Chicago.
LEVITT: Yeah, bad enough that they have Plexiglas between you and servers if that’s any indication. I don’t think there have been a lot of podcasts done in this particular Kentucky Friend Chicken.
DUBNER: So Levitt, what do you think of fat people?
LEVITT: Nothing… I’m not one of the people that really hates fat people. I know there are people who hate fat people, but I don’t really mind fat people. I mean, when people say they are so against obesity, it’s driven by some moral thing, I think, rather than some economic thing, I think.
DUBNER: Where do you think that comes from?
LEVITT: You know me, I got nothing to say about morality.
DUBNER: Fat people. In America, they're everywhere. The Federal government says that two of every three adults are overweight; and one-third of our children are officially obese. Over the past half-century, we've come to consume about 30 percent more calories each.
Why? Well, fattening foods are cheap, abundant and -- let's face it -- delicious. As problems go, this is a strange one. Throughout history, people have struggled to get enough to eat. In many countries, they still do, and charities like the Gates Foundation are spending hundreds of millions of dollars trying to help poor children eat more. Last week, Michelle Obama announced a $10 billion program to help American children eat less fat.
[Michelle OBAMA: So as we've seen, the surge in obesity in this country is nothing short of a public health crisis, and it's threatening our children, it's threatening our families, and more importantly it's threatening the future of this nation. ... Economic experts tell us that we're spending outrageous amounts of money treating obesity-related conditions like diabetes, heart disease and cancer.]
DUBNER: Gosh, no wonder everybody hates fat people -- they're bankrupting our nation. They're even threatening our national security:
[Michelle OBAMA: Military leaders report that obesity is now one of the most common disqualifiers for military service. Economic experts tell us we are spending outrageous amounts of money treating obesity related conditions, like diabetes, heart disease, and cancer.]
DUBNER: Here's Ezekiel Emanuel, a doctor and bioethicist who's an advisor to the Obama Administration on healthcare reform. He's also the older brother of Rahm Emanuel, the White House chief of staff.
Ezekiel EMANUEL: We're all focused on healthcare, diabetes and heart disease. But there's all sorts of things like the simple fact that heavier people, transportation is more. There's more spent on gasoline, more on jet fuel. People have had to change the size of doorways, the size of chairs on airplanes and in sports stadiums. So there's a lot of hidden costs as well to the increasing girth of Americans.
PEGGY: We're being blamed for everything, all the way up to global warming!
DUBNER: How do you deal with that?
PEGGY: I just rely on the fact that I know that I am a good, hard-working American person trying to contribute to the betterment of society and that there is a lot of stuff going on and being said that isn't true.
DUBNER: This is Peggy Howell. She's 5'9", 280 lbs. She wears a size 22 dress.
PEGGY: I was working for a school that was associated with a religious organization in Northern California, and I worked—I had gone through the school program and graduated and then was working for them, I was working as a student counselor and librarian and doing Accounts Receivable. It was a small school, so we all wore many hats. And at one point my boss came to me and said to me that I had to lose weight, else. And I said “or else, what?” and he said “Or else lose your job.” And I said “I’m sorry, I don't understand how my weight affects my ability to do my job. He said that the fact that my weight was too high was an indication that my life was out of control and that as such I was not fit to counsel other students.
DUBNER: So are a lot of people anti-fat because we see obesity as a moral failing? After all, we're talking about a self-inflicted condition here, right? But is there something else going on?
Eric OLIVER: My name is Eric Oliver I’m 43 years old, I’m a professor of political science at the University of Chicago.
DUBNER: How tall are you and what do you weigh?
OLIVER: I’m six feet tall and 190 pounds
DUBNER: What’s your BMI?
OLIVER: That puts me at a BMI of 25, which is technically overweight
DUBNER: I have to say, Eric Oliver doesn't look at all overweight; in fact, he's on "rangy" side. When he discovered that his BMI, or Body Mass Index, made him technically overweight, he began to wonder about the intersection of politics and science when it comes to obesity.
OLIVER: When we start designating people as overweight or obese, we’re immediately putting labels on them. We are defining that relative to some standard of deviance, and that in itself is a political act. By differentiating people according to their physicality, we immediately start creating political problems. But I think more importantly, obesity is one of these issues that--the science of obesity is very very complicated; linking anything to chronic health and predicting any kind of chronic health outcome is an incredibly difficult thing to do from a statistical standpoint. The interesting thing is most people don’t appreciate that fact. And when they start hearing information on obesity they really do so based on prior conceptions and prejudices and I think a lot of our understanding of obesity as a health issue is informed much more by our social prejudices against fat people, or by the particular financial incentives of the weight loss industry or certain public health officials, or the bureaucratic politics of organizations like the Center for Disease Control. These factors are really defining how obesity is being framed as a public health issue more than the scientific evidence itself.
DUBNER: Oliver has written a book called "Fat Politics: The Real Story Behind America's Obesity Epidemic."
OLIVER: The first thing I wanted to do was establish that in fact obesity was the health catastrophe that I assumed it to be and that everybody else was claiming. The more research I read into this, the more I started diving into the medical journals, the more I came to realize the scientific evidence linking body weight to all these health pathologies was far from clear cut. That, in fact the case wasn’t very strong at all, and the more research I started digging into then, why that was the case, the more I started hearing about findings that were hushed, politics that were going on within various bureaucracies to promote certain kinds of findings and suppress other kinds of findings, large debates within the scientific community that were not public about the nature of obesity and its relationship to health. And I came to quickly realize that there’s a much more interesting political dimension to this than actually a scientific dimension.
DUBNER: Wait a minute: the scientific evidence for the dangers of weight isn't very strong?! That sounds crazy. The Obama Administration argues exactly the opposite; so does my doctor. His name is Conrad Blum, and I should also say he's a professor of clinical medicine at Columbia University's College of Physicians & Surgeons.
Conrad BLUM: Overweight and the insulin resistance that go along with it would be underlying problem causing what we call metabolic syndrome, which is a constellation of heart risk factors, including high blood glucose levels and development of diabetes, as well as high triglyceride levels, high blood pressure and low levels of HD cholesterol, what we call the good cholesterol.
DUBNER: And what is your level of confidence when you say that overweight drives these diseases as opposed to being correlated. What’s your level of confidence that this is causal, not just correlated.
BLUM: My level of confidence if virtually 100 percent. I have seen a large number of instances where we are able to cure all of these complications of overweight and obesity by having people lose weight. So if we treat the underlying disease, which is overweight, we can, in nearly all cases cases, see the diseases disappear.
DUBNER: Holy cow. Who am I supposed to believe, the Obama Administration and my own doctor -- a smart, caring professional whose decades of experience tell him that losing weight makes diseases disappear -- or some rogue political scientist?
DUBNER: So here’s what you’ve written: “Obesity is neither a disease nor a cause of disease. “ I’m guessing that 9 out of ten or 95 out 100 people who would read that would say, what is he talking about of course it’s a disease or at least a cause of disease and yet at the very root level you say no. Explain.
OLIVER: Right, the difficulty with obesity as with any kind of chronic health issue is that we really don’t know the causal linkages between weighing too much and most diseases. Being very, very heavy is hard on your body. It’s very hard on your joints. If you’re a woman it causes an increase in certain kinds of hormones, which can contribute to higher rates of certain kinds of cancers. So we do know there are some causal effects of weighing too much. But if we look at heart disease, if we look at most cancers, if we look at stroke, even is we look at diabetes, and this is probably the most contentious issue, the causal linkages between having a lot of body fat and having these conditions are far from clear.
DUBNER: You write that in 2004 the Center for Disease Control estimated that obesity is killing 400,000 people a year. Right, do I have that right? That obesity is killing 400,000 people a year.
OLIVER: This is what they issued--They issued an article that was published in the Journal of the America Medical Association claiming that, yes, obesity was killing 400,000 people a year.
DUBNER: And you vehemently disagree, correct?
OLIVER: Well, what happened was, there were a number of problems with this report. One of which is it was based on data that were about thirty years old. Secondly, the report itself made some computational errors that called into questions the actual findings there, and the conclusions. Another set of research from a different division of CDC then later issued a report that said, in fact, that number was probably closer to more like 20,000 people a year. And in fact there were just as many people dying from weighing too little as there were from weighing too much.
DUBNER: And we’re back at Big Nick’s, home of the sumo burger.
JESSICA: OK, well, let’s see, there’s a lot of burgers on here. There’s a chili burger, chili cheese burger, oh a cocktail burger—I like the sound of it, but I don’t think I’m going to get that one. Ooh, “aloha burger” sounds fun. Oh God, I don’t know, I think I’m just going to have the Mediterranean burger, because it has anchovies on it, and I love anchovies.
DUBNER: What else is on?
JESSICA: Oh it’s Grecian burger with anchovies, slice of feta cheese, and tomato. “Second to none!” it actually says that.
DUBNER: So we eat more than we used to and we weigh more than we used to. Some people think this poses a terrible danger. The First Lady’s "Let's Move" program addresses some of this, like peoples’ access to healthy food. We couldn’t get Michelle Obama to talk about her program, but Ezekiel Emanuel described it for us:
EMANUEL: As you may know, the first lady has launched this “Let’s Move” campaign, which is aimed mainly at children, and has four pillars: the first pillar is to improve nutrition in schools, and to get more fruits and vegetables on the school lunches; the second pillar is more physical activity, so more physical activity at school, changing the built environment so there’s more walkways, more bike paths, trying to encourage participation in sports leagues; the third pillar is to give people more access to foods, so eliminating food deserts and such, so that people in the inner city and in rural areas where they don’t have access necessarily to fresh fruits and vegetables, or they don’t have grocery stores that carry them, to increase their access; and the last is to really give parents information that they need to make healthy choices, so that they can have some reliable and effective information to act on.
DUBNER: Those sound like fantastic ideas. How well do you think it work?
EMANUEL: I think—I detect a bit of skepticism in your voice, and I think that any single one of them alone is probably not sufficient. Together, as well as with a change in social attitudes around obesity and around each one of those issues—eating better, more physical activity, food deserts, I think they can make a big difference.
Brian WANSINK: There's a couple of really critical things that are missing from the "Let's Move" policy. It's been tried 15 different times and it's never been effective.
DUBNER: Brian Wansink is the author of "Mindless Eating," and he's a researcher at Cornell who for years has been studying how we eat. He also spent some time as a top nutrition official at the U.S. Department of Agriculture. He helped reshape the food pyramid. When Wansink looks at the war on obesity, he sees a lot of people with an incentive to hype the problem.
WANSINK: There's a tremendous number of people who profit by hyping obesity. I don’t think it’s the epidemic that a lot of people paint it as, but here’s who profits: there’s a lot of diet doctors, there’s a lot of bariaticians, there’s a lot of fly-by-night super diet drug people who benefit by making this the biggest threat to the world, but there’s a huge number of academics who benefit by doing this, because there is so much money in grants, whether it be the NIH grant, or CDC or whatever, that is out there, if academics can make the case that this is a huge, fat world that's just going to heck -- they benefit. I'm not saying there isn't a problem. But I'm saying it gets really blown out of proportion because there are a lot of people who are motivated to do so.
DUBNER: But here's the thing. Even today, without universal health care, the government pays for 45% of all health-care costs in the U.S. So I'm paying for your medical costs and you're paying for mine. In fact, one economist has calculated that every time you order cheeseburger instead of a salad, you add $2.50 in collective long-term healthcare costs. Now, if these costs are being driven higher every time I eat something fattening, what are you supposed to do about it? So I asked Ezekiel Emanuel. Is it time for a cheeseburger tax?
EMANUEL: I can’t answer that question. That's a political question: when is the right time for a cheese burger tax? I think you've got the wrong Emanuel brother.
DUBNER: You know, a tax is one way. As you yourself know, in Freakonomics, the other alternative is to reduce the price of things that make you healthy. So we could actually reduce the price of fruits and vegetables, and encourage their consumption by having them be less costly. So there are lots of ways of doing this, and a tax is, you know, that’s just one approach, and by no means the only approach We know that how you display items, in, say a school cafeteria, where you position them and how you make them look, in terms of whether they look appetizing or whether they look—whether the vegetables look wilted. All of that stuff makes a difference.
DUBNER: But how much difference do such well-meaning nudges actually make? I asked Brian Wansink.
WANSINK: When we look at calories labeling, for instance, the people it seems to have influenced the most are the people who already do eat pretty well. It's influenced the people who already do know, roughly, how many calories are in something. And I think the reason the needle is not moving is that what it did is it stirred up a bunch of dust and got a bunch of people waving their arms and clapping, but it didn't influence the people who probably really need to change. Because they either just don't care, or it's too much effort.
DUBNER: Too much effort." Why? Because eating is fun. It's social. It's life-sustaining. It's finger-lickin' good. So how are we supposed to think about all this? Americans have gotten heavier -- but this might not be as dangerous as we've come to think. A lot of smart people are working hard to get Americans to eat better -- but, given the quirks of human nature, a lot of this effort will likely be wasted. And then there's Eric Oliver, who says the reason so many people think fat is so dangerous is because obesity researchers -- even those who write for top medical journals -- are woefully unsophisticated when it comes to statistical analysis, and that they've failed to prove that fat is the cause of health problems like diabetes and heart disease.
DUBNER: So it sounds like you’re saying that calories are relatively cheap, and that’s good because we need calories and we enjoy them, and that’s not bad because weight in and of itself is not dangerous. So really what might be the best medicine is for everybody to just relax a little bit?
BIG NICK'S COOK: This is, uh, ice cream burger.
DUBNER: An ice cream burger?
COOK: Medium rare.
DUBNER: Medium rare? Can you tell me what’s in the ice cream burger?
COOK: It’s like, uh, cookies, chocolate chip cookies, with ice cream in the middle. You have vanilla, chocolate or strawberry, and uh…
ANNOUNCER: This episode of Freakonomics Radio was produced by Stephen Dubner (BMI 24.8, normal), with production help from Molly Webster (21.0, just perfect fightin’ weight) and Jesse Baker (the winner, with a 20.4 BMI). Subscribe to this podcast on iTunes, and you'll get the next episode in your sleep. Go to freakonomics.com to read more about the hidden side of everything. Thanks for listening!