Maintenance Phase - Is Being Fat Bad For You?

Episode Date: November 16, 2021

For nearly four decades, Americans have heard a simple story about health, longevity and obesity. This week, we learn it's a little more complicated. Thanks to Katherine Flegal, Paul Campos, Jeff Hunger and Jason Salemi for helping us research and fact-check this episode! Support us:Hear bonus episodes on PatreonDonate on PayPalGet Maintenance Phase T-shirts, stickers and moreLinks!Katherine Flegal’s “The obesity wars and the education of a researcher”Walter Willett's " Evidence does not support benefit of being overweight on mortality"Flegal’s 2005 paperFlegal’s 2013 articleWillett’s 2016 meta-analysisThe infamous 2004 CDC paperFat: A Cultural History of ObesityPaul Campos's "The Obesity Myth"Walter Willett’s Food Fight           The obesity research that blew upFlawed methods and inappropriate conclusions for health policy on overweight and obesity: The Global BMI Mortality Collaboration meta-analysisDoes Body Mass Index Adequately Convey a Patient’s Mortality Risk?The Weight of Medical Authority: The Making and Unmaking of Knowledge in the Obesity EpidemicObesity: An Overblown Epidemic? Commentary: On ‘public health aspects of weight control’Obesity And Its Relation To Health And DiseaseDoes Being Overweight Really Reduce Mortality?Individual and Aggregate Years-of-life-lost Associated With Overweight and ObesitySupport the show

Hi everybody and welcome to maintenance phase, the podcast that's just concerned about your health! Oh my god! We're in your mentions on Instagram. You're glorifying it! That one really lived or died by the line reading, and I feel pleased with how it turned out, if I'm honest. I'm Aubrey Gordon.

I'm Michael Hobbs. This month, by astonishingly popular request, our bonus episode for Patreon patrons at every level is the HBO Max documentary mini series The Way Down. Yes, I have been told that I have very disappointing opinions on this matter. So, enjoy those. And today we are talking about is being fat bad for you.

I'm both very excited for this to get the Michael Hobbs like terrier digging through a million facts kind of treatment. I am also nervous about it because this is the kind of thing that people with profound anti-fat bias use against fat people all the time. Yeah. Any time you open up this conversation, it's like opening up Pandora's fucking box

for fat people. This, like this little intro is so telling, I think, because the way that fat people and thin people experience this conversation is worlds apart. Yes. Thin people experience this conversation as like, well, you know, I've read newsweek the other day that because everybody's fat, we're all going to live, you know, 13 years less than we thought we would. And fat people experience this as like, you are going to die. Yes. And I would say fat people experience it as you are going

to die because often thin people who read those newsweek articles then turn around and tell fat people you are going to die. Exactly. When a thin person decides to tell a fat person, we're going to live 13 years less or whatever because of you. Yeah. Because you're fat. Whether or not that thin person intends to do so, the idea that that introduces is, I'm superior to you. Yes. Because I have figured out how not to do this thing,

and you are failing because you have not figured out how to do this thing. Right. Antifat bias has, I would argue, a more decisive impact on fat people's health than actual just physical body weight. Then add a post tissue? Correct. A term that I have read far too many times this week?

Yes. All right. This is so many caveats. I know. Let's keep caveating. Just never, never start. Let's never start. And only be like, one more thing before we get into it.

My friend has this joke that every left-wing podcast is just people saying, I'm just gonna zoom out for a second over and over again. And that's what we are doing. Oh no, that's me. To me, I think a really important, god I'm doing it, or I contextualization thing about this issue is, people, most of the academic literature, treats this as some sort of footnote.

But to me, it's very important to acknowledge that stigma against fat people and the belief that fat people are unhealthy long predates any science showing them. And there's this really good book called Fat Cultural History of Obesity, where they identify the first reference of an Obes obesity epidemic was in 1620. Right. You know, the Catholic Church invented the seven deadly sins, and one of them was gluttony. And sloth. Well, exactly. Yes. Yeah. So like, there's always been this moral component, and there's always been this out-group component. So something I didn't know until I read this book was that diabetes used to be known as the Jewish disease.

What? The idea was there was something about Jewishness that gave people diabetes. It was like a genetic predisposition, basically. Oh, boy. So this has always been associated with like, this is a group that I do not like, and I'm going to assign to them

like some sort of health status. Right, I mean, if we think back to the BMI episode, right? The earliest codification of the BMI was the fattest 15% of people would be considered overweight, right? It didn't have anything to do with health risks. It didn't have anything to do with anything, but the fattest among us need to be defined in this way, right? Then you create a bunch of funding streams

to find out why it's so unhealthy and so terrible to be what we already think of as terrible. Right. It can sound a little bit conspiratorial to be like, everybody hates fat people and like, that's why all the science says this. And so I do think that that's overly simplistic, right? But I also think that it's also overly simplistic

to think that this has no effect. Yeah. So the earliest studies of what does it do to your health to be a fat person? I'm gonna skip a lot of this because we talked about it in our BMI and obesity epidemic episodes, but the only data that was available was from life insurance companies.

Right, this is the 40s, 50s kind of era, yeah? Yes. So like, think about who had excess income in the 40s and 50s to spend on life insurance. It's going to be disproportionately white, overwhelmingly male, middle class, upper middle class, and straight up wealthy, right? There's a whole wide, wide range of people that you're missing. Exactly. Basically, the big innovation at this time and the closest thing we get to reliable information

on fat people and health is the rise of the cohort study. So are you familiar with this? No, no. I mean, I know cohort studies exist. But I don't know what the rise of them. I'm not fucking with you. I don't know. I feel like I'm being trapped somehow.

So basically everyone knows these life insurance tables are bullshit for all the reasons you just said. And so what they start doing in the 1940s and the 1950s is they start getting these large groups of people and they get like a representative sample of the country. So they start getting together like an entire small town. You know, one of the most famous ones is like a bunch of nurses. It's like 70,000 nurses, huge numbers, and then you track the same people over time. Yeah, I mean, it's essentially like the seven-up series. Yes, but on science, right? Yes. That's like, we're checking in periodically. We want to sort of see how you're

doing on these specific sort of like sets of measures. Yes, after a couple of years, after a longer periods, I mean, some of these cohort studies have been going for like decades at this point. So once you wait long enough, people start dying. And then you can get into all of this risk relative, you know, mortality rates rising kind of thing of like,

okay, so why, if we would expect 25 deaths, why are there 50 deaths among fat people? Like that is how you can start doing these gradations and figuring out like what is killing Americans? And so the sort of the the the central issue with calculating these mortality rates is you can't just look at the raw numbers, right? So if you say like, okay, if we look at normal people, 500 of them died, but then if we look at smokers, a thousand of them died, right? So if you say like, okay, if we look at normal people, 500 of them died, but then if we look at smokers, a thousand of them died, right? So it's like, oh, okay, so smokers are twice as likely to die. But that's too simple, right? Because smokers are not the same as non-smokers. Smokers are much more likely to be poor. They're much more

likely to be uneducated. They're more likely to be unemployed. They're slightly older than the rest of the population. There's all these other factors. So you have to sort of adjust so that you're comparing like poor, uneducated smokers to poor, uneducated, non-smokers, and then you can say, ah, okay, so this is what accounts for the smoking. Right, and if you don't do some level of statistical control, then you do what your brain is sort of wired to do, which is fill in the blanks with what you think you know, which are often not rooted in data or science or anything. Exactly.

So what you just said is basically the Rosetta Stone for this entire episode. Because if you look at the raw numbers, it's true that very fat people have shorter life spans than thin people. Yeah. It's complicated for the lower weights and there's a lot of scientific debate about sort of when that association kicks in and we'll get into it. But that correlation, that statement that very fat people are more likely to get heart disease and diabetes and everything you've read about in a million Newsweek articles, that's never really been debated. The debate is about what the association means.

Because obesity is not the only thing that's associated with having a shorter lifespan. Catholics live two years longer than evangelicals, and Jewish people live two years longer than Catholics, people who live in West Virginia die six years younger than people who live in California. One of the weirdest statistics I came across is that people with masters degrees have 10% higher mortality rates than people with PhDs. What? So next time you see somebody posting about like, hey, I got my master's degree on Instagram, go into their mentions like, you're glorifying in having a master's degree. I'm just concerned about your health. I know.

Quit your master's program. Another really consistent one is that unmarried people have between two and a half times the mortality rate of married people. What I love about the unmarried statistic is that when you tell people, okay, unmarried people are more likely to die. You can like see the gears in their brain start working.

People are like, oh, it's probably something to do with, like if you fall down the stairs, if you're a married person, like someone is there to call 911, or maybe somebody's gonna hassle you about getting a doctor's appointment for like the lump in your chest. If you're married, whereas if you're not, you might just like leave it for another year.

Like people will start speculating about what the sort of the real reason is for this association because we all on a gut level understand that like having a piece of paper, the marriage license is not extending your lifespan. This is also how you get that fucking garbage shit that's like, it'll show up in like, people magazine, it's like a pull out box that's like, dog owners live five years longer than people who don't own dog. People who own subcompacts have longer, happier lives than people who drive SUVs. Like all of that utter garbage comes from either findings that are not great or people not digging far enough into the findings before translating

them into popular media and then popular media running with that shit. Exactly. No one looks at all these other associations and immediately leaps to, oh, this is how we have to fix it. Like nobody is saying that like no matter what you go into the doctor for, they should be like, uh, have you considered converting to Judaism? Yeah. This isn't actually a difficult concept for people.

What's difficult is that we have been told this extremely simple story about obesity for so long that it's really hard to look at it any other way. And the thing you have to constantly remind people of is that obesity is not a behavior. Obesity not a behavior. Obesity is a characteristic. People become fat for all kinds of reasons, and people live their lives as fat people with

all kinds of habits. There are fat people who don't get any exercise. There's fat people who get tons of exercise. There's skinny people who get no exercise. There's skinny people who get tons of exercise. These are all overlapping circles. And so the entire debate over obesity is where on the spectrum does it fall.

So is obesity more like smoking? In that it's a behavior that we can very clearly link to causing all of these health problems and shortening your life? Or is it more like having a master's degree? Where it's like, okay, it's basically a cluster of other correlations. Yeah, I mean, first of all, this is about to be maybe our methodology,

Queenia's episode. I'm getting the sense. Methodology, Empress. Methodology, Galactic Senate. This is the project of creating and reinforcing an outgroup status. Yeah. And making people believe that it is objective, that it is scientific, that it is beyond reproach, and that it is natural for you to feel like fat people

are lazy and gross, because that's what they are, because science tells you they are, right? Like, it's just bizarre that we try and take this stuff in a vacuum and just parrot it out as gospel. This is the hardest thing about this, is because you have to keep in mind issues outside of the data. Yeah, so one of the most famous findings from these is in the 1990s, the Journal of the American Medical Association published a study that said that left-handed people die

nine years younger than right-handed people. What? This was actually something that I was told growing up because I'm left-handed. And like, my whole adult life, I've been thinking about like, why? Like, why am am I gonna die so young there's these like crackpot theories about like driving what like the stick shift is with your right hand or something but also who drives stick anymore I know like I don't know man but so what it actually turns out is essentially the researchers looked at the population of 70 year olds

and they said okay well there's you know roughly 12% of the population of 70 year olds and they said, okay, well, there's roughly 12% of the population is left-handed. And then they looked at 70 year olds and they're like, oh my fucking god, only 3% of these people are left-handed. So all of the left-handed people must have died. It's like they're dropping flies and we're only left with this much smaller population.

But of course, these are some of those scathing letters to the editor of a medical journal that I've ever read. All of these people write in and say, if you're looking at a population who's in their 70s in the 1990s, these are people who grew up in the 20s and 30s. And in the 20s and 30s, if you wrote with your left hand, they would make you write with your right hand. So the reason why there are only 3% left handers in that age court isn't because there's like a genocide of left-handed people, it's because due to other social forces,

the rate of left-handed people is like artificially low among old people. I will tell you this, my grandfather who passed away 15 years ago ish was like an extreme left-handed pride. Oh, yeah. The level of vindication that this guy has get in the past. That is, Jimmously, is through the roof.

Well, look, Aubrey, all hands matter. I don't know why he was being so weird about it. All hands matter. All hands, fire. So, I mean, the left-handed thing, I mean, first of all, I just have kind of a chip on my shoulder. There's a left-handed person about this. but also it's just important that you can't

only look at the data. That data about left-handed people, you can slice and dice it, you can control first smoking status, and you can do all kinds of statistical mumbo jumbo on that data, but it's only going to drive you to a slightly less bone-headed conclusion. So this leads us to meet our protagonist for this episode. Oh, we have a protagonist? Yes, a woman named Catherine Flegal. Oh, sure. You know this.

Oh my God, Mike, I'm so excited. I forgot about this. All right, put us in space and time. Who is Catherine Flegal and like what is going on in the late 1990s? So Catherine Flegal is a statistician who works at the CDC and I know that she waited to tell this story until after she was retired. Yes. So Catherine Flegal is at this time a statistical researcher for the CDC. She got her bachelor's from UC Berkeley. She did a PhD in nutrition at Cornell. Her work has always focused on obesity.

And she's one of the first people to notice, like, hey, Americans are getting fatter. Like, she's one of the first people to start publishing on this. And she was actually in, I believe it was Geneva at that WHO meeting where they changed the BMI categories. Oh, whoa! Holy shit! She is like deep in this field,

and like one of the earliest people, like just trying to get the message out that like something is changing in the American population, and like people are getting fatter. So in the year 2000, she starts working on a paper about obesity and health. She's been at the CDC for a while.

There's this kind of longstanding debate about like what does it actually mean for your health to be fat. And she decides to start looking into this in a very concerted way. I'm going to find the best data. I'm going to try to really answer this question once and for all. What she does not know is elsewhere at the CDC. Another team is also working on this.

So in 2004, we get the infamous paper that is called Years of Life Lost to Obesity. No. We've talked about, we've debunked this like four times on the show already. It's basically this big CDC study that makes huge headlines everywhere for saying that obesity causes 365,000 deaths per year.

Yeah. It also says that obesity is poised to overtake smoking as the number one cause of death in America. This is like a level of deaths that like you would know someone who died just of fat. That is a very large number of people to just keel over because of their fat. This is sort of the impression that certainly that the general public is left with. Oh yeah. After the reporting on this, right? So this paper comes out, gets a ton of media coverage, less than a year later, Catherine Flegal puts out her paper.

And in her paper, instead of showing that obesity causes 365,000 deaths a year, her paper shows that obesity causes 112,000 deaths, but it also reduces deaths by 86,000 because slightly overweight people are actually less likely to die. Right, this is what they call the obesity paradox. Yes.

Which is my favorite thing to yell about, because it's only a fucking paradox if you can't imagine fat people living healthy lives. Catherine Flegel has some very salty papers about the obesity paradox. Really? She's like, it's not really a paradox. It's just like, maybe it's just not universally bad for you. Like, maybe it's complicated.

Totally. It's not really a paradox. It's just you assumed this wasn't possible, then researchers actually looked into it, and it is possible. Exactly. Calm down. And sometimes you'll see scientists just kind of rejecting this out of hand, they're like, ugh, there's no biological mechanism

that would make fat people live a bit longer. And it's like, really, you don't see any reason why people who carry around extra energy on their bodies would live longer from certain conditions? Like, I actually don't find this difficult to believe at all, considering how many diseases cause you to sort of waste away as you get older. It makes sense they would live longer from some of these conditions

and that gives them more time to recover. Yeah. There's also actual studies on this. 80% of deaths in America are of people 70 and above, right? So one of the most common causes of death and disability in old age is falling down and breaking a bone, especially breaking a hip. One third of people who break a hip die within a year.

And so this sounds really fast-ciled, but fat people just have more padding on themselves. So there's actual studies that find that the skinniest people are the most likely to die after suffering a hip fracture. So once you get into the actual causes of death and you're actually curious about this phenomenon rather than simply rejecting it,

it's like, oh yeah, it actually makes a lot of sense that under certain circumstances for certain people being a little bit fatter is actually better for mortality. Yep. So basically, I mean, the number one finding of her paper is that like people in the BMI overweight category are slightly less likely to die. So a little bit of fat has like some protective effect

on mortality rates. The other big finding is that skinny people are more likely to die. So in the fatdest category, like the obese category, she logs 26,000 deaths. In the skin obese category, she logs 26,000 deaths. In the skinniest category, she logs 33,000 deaths. Yep. So one of the quotes that goes around about this,

this is sort of how it ends up in the mainstream media coverage of it is, given current government guidelines, it appears that the average person is better off being 50 or even 75 pounds overweight than 5 pounds underweight. This is a thing that also gets sort of thorny, right? It's worth noting, very thin people are more likely to die than very fat people.

And there is no cause for you as a layperson to then start talking to very fat people or very thin people about how they're gonna fucking die. I like it when you stand up for thin people. You like it? Won't someone think of the thin? I like it when you say thin rights. There's all kinds of actually cohort studies

that show the same pattern of like this weird spike for thin people, a little bit reduced mortality for people that are like a little bit overweight and then a higher curve for people that are like a little bit overweight, and then a higher curve for people that are fat. They call it the U-shaped curve, even though it's like more like a Nike swoosh, but it's an extremely consistent finding in this kind of research.

So we now find ourselves in 2005. There's this 2004 paper that finds that like obesity is like really bad for you, overweight people are gonna die, fat people are like totally gonna die. It's just like really, really, really bad for you. Overweight people are gonna die. Fat people are like totally gonna die. It's just like really, really, really obvious deep line. And we've got 365,000 deaths caused by obesity every year. And we've also got Catherine Flegel's 2005 paper that says it like,

it's really not that many people, like once you subtract the lives that it saves from the lives that it takes, it's like 25,000 deaths a year due to obesity. And there's this weird thing with like skinny people being less healthy and like, it seems actually to be like good to be like five to 10% overweight.

Like there's now these two papers, both of which are from the CDC, saying completely different things. Right, and one estimate is 90% lower. Yes. So to this day, this is still framed as like a scientific debate and like two different ways to look at obesity data and like who can say, but the important thing to know about these two estimates is that one of them is wrong. Like wrong. The first thing that happens with that 365,000 estimate is that people look into the numbers and there's errors.

Just like straight up transcription errors. They put the deaths in the wrong years. Like human error in Microsoft Excel. Also, there's weird methodological stuff. So remember how I said earlier that when you look at tobacco deaths, you can't just count up the smokers that die because you have to control for all this other stuff because it's not a representative sample of the population.

What they did in this study, when they say, obesity is about to overtake tobacco, they adjusted the tobacco deaths downward because they're like, well, people who smoke are more likely to be poor. We have to artificially make that number smaller to make it more valid, but they didn't do that with obesity deaths.

Right, struck by lightning, congratulations. If you're fat, you died of obesity. This is literally like the sophistication of the analysis, basically, right? It's astonishing that this number clawed its way into the popular imagination and still gets repeated in non-academic sources, like all the fucking time.

No, I know. Like I got a fact sheet from a lobbying organization in the last like three months that was like, you know, 360,000 fat people die of obesity every year. And I was like, yes, excuse me, what? The earlier study also, I can't believe they did this. Some of their cohort studies ended in the 1970s. So like some of the deaths were in the 1970s, even though this paper is being published in 2004,

but like the heart attack cardiovascular death rates in the 1970s were sky high. You're actually much less likely to die of a heart attack as a fat person now than you were as a normal weight person in the 50s and 60s. If you look at the death rates, they've all been declining for years, even as the population has gotten fatter. Right, and a lot has happened in technology and medicine since then. Right, the other problem with these studies is that they're built exclusively around BMI categories. So every single person in these big cohort studies is organized in like normal way Wait, can that be can that be your canonical BMI?

I every time I say a BMI number. I just like cringe inside also every time I say like obese I also cringe like I hope that it's clear for my general tone and personality that I'm putting giant quote marks around these terms at all times. Yeah. Normal weight. I don't believe in these things, but it's just going to be much easier if I don't have to say quote unquote.

I use one of these adjectives. So I feel deeply weird about the way that I'm speaking about this issue right now. I will also say, many, many fat people experience the terms quote unquote obese and obesity as slurped. Yes, I've talked to one fat person ever in my time of doing this project where I've talked to thousands of fat people who are like, I feel neutral about the word obesity. Yeah, everyone else has said, I feel deep shame about it. I feel like I'm being judged. I feel horrible.

It makes me think about self-harm. I know. I think there is this belief that because it's a medical term, it can't hurt people. Lots and lots of medical terms hurt people. But they're saying person with obesity now. No, it just... Fuck!

Michael, someone corrected me on Twitter and was like, actually, what you should be saying instead of fat person is person with obesity. And I was like, actually, what you should be saying instead of fat person is person with obesity. And I was like, get out of my mentions, you grandma. The worst is person with overweight. Oh, it's like what? It's so weird.

But so the problem with these categories for mortality research is that a lot of those cohort studies rely on self-reported BMI. So you ask people their weight, you ask people their height, and then you calculate that like they're overweight or they're normal weight or whatever. Yeah, the problem is that when you do this, a huge number of people end up in the wrong categories

because people, I mean, I don't wanna say a lot about their weight, because like a lot of people don't know accurate, like I do not know my weight, I have not weighed myself in like five years. So like if somebody asked me my weight, I would be wrong. But then the problem with self-reported data is skinny people will lie a little bit about their weight. Like if you're like 150, you'll say you're like 145.

But if you weigh 400 pounds, you'll say you're like 325. Yeah. The larger you are, the more weight you will take off. But then there's also weird confounders that like skinny men will add weight to themselves. They'll say that they're 185 when they're actually 160. Right. What you're telling right now is the story of my first driver's license. Wait, were they asked you your weight and they don't weigh you? Yeah, totally. And I was like 250 pounds.

I'm like, what are you talking about? I'm just going to leave me alone. So let's say you have two people and they're both 5'8 and they both say that they're 180 pounds. So that's the data in your spreadsheet. But in reality, one of them is 185 pounds and they're cutting a little bit of their weight off.

And the other one is 200 pounds and they're cutting a little bit more of their weight off. In the actual numbers, this isn't actually that big of a deal and people who defend self-reported data, they'll say, well, when people lie about their weight on average, they only really lie by like whatever, two, five, 10% something like that. It's not that big of a deal.

But it's not actually about how many pounds they're cutting off of themselves. The problem with those two people is that the cutoff between overweight and obese is 190 pounds. So the person who's 200 pounds, who says that he's 180, he just jumped from one category to the other. People have actually done studies where they compare data that self-reported and data that's actually measured, and some of these studies, the normal weight participants, 30% of them should have been classified

as overweight or obese. And so look, the BMI categories are bullshit. And like this, this is nothing about people's individual health. And like, I don't wanna make it sound like I'm giving any credibility to this. Yeah. But the entire purpose of these studies is comparing people in different categories to each other. Right. If you're comparing dogs to cats and you're like,

oh, 30% of the cats in our sample are actually dogs. Yeah. And we have no way of knowing which cats those are. Like, which ones are actually dogs in disguise? Your entire study is garbage. Yeah. Because you're not actually comparing different categories. Totally. So another reason why Catherine's study is better than the earlier study is that she throws

out all of the self-reported data. You can't just mix bad data and good data and then say anything valid about a phenomenon. Right. Again, this is framed as like a scientific debate. Like some people say 365,000 deaths, and then like this wacky Catherine Flegal lady says it's like way smaller. But the CDC corrected the 365,000 number, they put out explicit guidance

that they weren't going to use it. So in a press release, they say like, yeah, we're no longer standing by this number. We are standing by Catherine Flegal's work. It's just better data. Right, and she didn't write a bunch of conclusions based on typos. Exactly.

That's the thing that is like wild to me about this whole story. It's not like Nata's methodologically sound. It's like total nonsense. This is like where I think the obesity epidemic as a moral panic is really instructive. Because the pattern that you see in moral panic over and over again is, what do we not need evidence to believe? Like, what are the overall societal narratives for which we will put aside

these like pretty basic methodological considerations, right? We won't apply as much scrutiny, the CDC, and like, you know, the Journal of the American Medical Association and these like very high level public health institutions were willing to print something that in the methodology says we are assuming all deaths of fat people are because they are fat. Yeah, they were just like, he sounds good. It's astonishing.

No one caught or seemed concerned with this very, very bald statement of bias. Like there's no other way to talk about that statement, that a statement of bias, like there's no other way to talk about that statement, that statement of bias, right? So despite the fact that Catherine Flegel's paper is just like better than the previous paper, there is huge backlash. So this is where we meet the antagonist of the episode. Are you familiar with somebody named Walter Willett? I mean, I wasn't six months ago, but I absolutely am now. What do you know? What I know about Walter Willett is that he worked,

does he still work at the Harvard School of Public Health? He was at this time the chair of the nutrition department at the Harvard School of Public Health, yeah. And I feel like everything I know about him is a spoiler for this story. And through like the weird Twitter explosion of people being like, oh yeah, I work on a different issue and he did this to me too. That was a good week on Twitter.

It was a great week on Twitter, like for you and me specifically. Like methodology fight you. For like a month, this dude was my Rachel Hollis. That's what I'll say. So Walker Willet is like a extremely prominent figure in public health. According to some accounts he's the most cited nutritionist in the world. He's also, I think this is very important. He also came up with that generation of public health people who were like screaming about obesity for years

and nobody was listening. And then once people started listening, I think it left a lot of people in that generation with like kind of a chip on their shoulder of like, this is my issue. I was talking about this before anybody else was. And like they really want to guide like the way that this issue is framed for the public.

He also has like really bad attitudes about weight and about fat people. So during the events that are about to ensue, he gives a bunch of interviews. You know, one of the quotes he says, next to whether you smoke, the number that stares up at you from your bathroom scale is the most important measure of your health. He also has this weird thing. He tells NPR the weight you should aim for is the weight you were at when you were 20. He says, for most people, our ideal weight, if we weren't seriously overweight, is what we weighed when we were 20. So it's like, you should aim for what you weighed when you were 20 unless you were fat, in which case it should be lower presumably.

Right. I was going to say like, if his thing is like aim for the weight you weighed when you were 20, unless you were fat, in which case, it should be lower presumably. Right, I was gonna say like, if his thing is like, Ampere the weight you were when you were 20, done and done. I know, that's the thing. I win! I can't own. The same size as when I graduated from high school, not quite but close.

It sounds like he's a thoughtful researcher in a lot of ways, and when it comes to fat people, his brain goes into the mode of like, I've already decided what I think of fat people. Exactly. So we don't really know this story from Walter's side, but from Catherine's side,

after her study comes out in 2005, she starts getting calls from journalists who are like, I am calling to write about the criticism of your work, and she's like, what criticism? They're like, oh, well, I got a call from this guy Walter Willett at Harvard. And he says you've published this study that's like methodologically flawed. At one point, he calls her research naive, deeply flawed, and seriously misleading. And she's like, what?

Yeah, which is like, that's mean. Yeah. Like, it feels like a way that professional men talk to professional women to dismiss them. Exactly. Like, oh, that's naive. So I'm going to send you a little excerpt from the article that Catherine Flegal writes about this in this summer, summer of 2021. Okay, great.

Quote, Almost as soon as our article appeared, symposium was scheduled at Harvard for the express purpose of criticizing our article. The lineup consisted of a small number of vocal critics mostly from Harvard itself, all attacking our work and asserting that their previous research somehow showed that our estimates should have been higher,

although their previous research had not even addressed the topic of estimating numbers of deaths. The presentations at the symposium did not mention the multiple errors in the 2004 article. One speaker described us as having no biomedical background, even though the four authors of our article were well-published senior scientists, all with doctoral degrees in nutrition or statistics

and one with a medical degree from Harvard Medical School. Jesus Christ. Right. Seeking to maximize media coverage, the organizers arranged for the entire symposium to be webcast live and encouraged reporters to view and report on it. What I am learning from this quote is that all these

well-published senior scientists are up on their high horses with their longer life expectancy and their doctoral degrees. 10% longer, man. None of these masters degree. These sickly in their doctoral degrees. 10% longer, man. None of these masters degree, these sickly people with masters degrees. Shumps. Yeah. One of the things she mentions in this paper is that like she was invited to attend this

symposium, but was not invited to speak. Fuck, that is such an aggressive move. It's such an aggressive move. I also think on some level, like holding a symposium to criticize a piece of work that you don't like. Like I honestly think like some of this is fine. Like there are elements of this that is okay, but what she finds over and over again

is the actual rhetoric that they are putting out and that Walter Willett is putting out is this idea that like the data is fundamentally flawed and the methods are fundamentally flawed and the methods are fundamentally flawed. So it's not, well, she made these choices and we would make other choices and these are why we would make these other choices. It's all this weird, bad, faith stuff.

It also feels like I'm not talking about this guy in particular, but often in the minds of people with deep-seated anti-fat bias, any acknowledgement that fatness might not be as horrifically unhealthy as we have been led to believe, translates to, then people will think it's okay to be fat, then people will intentionally get fat or let themselves get fatter. Exactly. Then we'll be overrun with fat people,

which is like a nightmare for them. Exactly. He constantly compares her work to the previous paper that found 365,000 deaths, but he doesn't mention the previous study had been corrected, and that it has like errors in it. Yeah. He seemed to talk about it as like this weird, Kathy Flegal joint where like she went out of her way to publish this like strangely ideological research when she, she's like, I work at the CDC after she got her data. She's been four months with the higher ups checking her data and stress testing it.

It feels very much like some interloper just shows up and figures out that it's probably not going to play great for him to take aim at the CDC, which is where this research originates. So he instead switches to like an ad hominem approach. And it's like, it's about this woman. It's also so funny that to people outside of this world, he starts telling them random reporters for like national publications. He's like, you know, the real problem

with Catherine Flegel's work is that the BMI is problematic. Oh, fuck off. Oh, fuck off. Like, of course, Catherine Flegal is like, the author study also used BMI. You have shown no interest in your entire career in like the ways in which the BMI is problematic. Like this is not work you have done,

you've not written about this, you haven't rejected other studies that used BMI because the entire fucking field uses BMI. But then I, like, I'm the problem for using BMI and you think we should use this other estimate that also use the BMI. Right. It feels like a little bit like the research equivalent of Stockholm syndrome with the BMI, which is like, it's terrible and it's sort of an open secret that it's terrible for like a bunch of reasons, but also now in order to make research that you get, that can be in conversation with other research. It is the way that researchers talk about size and health.

It's like the measure that people use. So you can decide to opt out of BMI, but then you're also kind of deciding to opt out of your research being like considered in concert with other more damaging research, right? Exactly. And like this goes on for years. Yeah. Blog posts start showing up on like the Harvard website that say that she's been demoted from the CDC and her paper was retracted. And she's like, what? Like, I won an award. Like, I got to work. It was work. Everything's fine. I go to work here every day and people still like me and work with me. What are you talking about? Exactly. And like, the fucking, I mean, there's no evidence whatsoever that Walter had anything to do with this. But like, someone updates the fucking Wikipedia article for obesity.

Jesus Christ. It included her article, and then someone said that it had been like discredited. What are you talking about? There's just like this weird shadow campaign to make it seem as if she's some like rogue statistician. She's like looking around and she's like, no, everyone thinks this is fine. I get so exhausted by this as a fat person, as a woman, definitely. And as a person who cares about like having conversations in good faith. Totally, exactly.

Like it's such a fucking soap opera. It's weird, hey. You know how all you have all this garbage shit to deal with at your job, and you've got a coworker who's totally unreasonable and weird and you can't stand to be around them? So do people at the CDC. Yeah.

Oh, got it. The thing that I have been taught to trust ungritically is from like deeply, deeply, deeply human sources. And that feels like the headline of this story to me. I mean, yeah, my headline for this is that academia is basically the big brother house. What? Is it a fight's going on? It just sucks in there. It's the big brother house. What? I can't. This little fight's going on.

It just sucks in there. Plutal. It's the big brother house. But like, people are constantly running campaigns to get people kicked out of the house, but no one ever actually gets kicked out of the house. That's right. That's right.

That's right. So fast forward to 2013, partly in response to the criticisms of her 2005 article, Flegal starts working on a much bigger meta analysis. So originally she just had these like two datasets from American data, but what she does is she looks for all other datasets. Like you know there's hundreds of studies going on about like obesity and health at any given time. Like it's kind of absurd. You find these random Norwegian cohort studies and the South Korean

nurse collaboration or whatever. Right, India, Australia, all around me. Exactly. This is a question that the entire field of science wants to answer. So Catherine Flegal does a pretty normal meta-analysis where she looks at every single study that's been published on this. And she publishes a meta-analysis that includes 97 studies and 2.9 million people. And she finds the same thing. Again, we have this spike of mortality for the thinnest people. And then you have a reduction in mortality for the overweight people and then it's higher for fat people.

So I interviewed Catherine Fliegel for this and one of the things that she noticed is that oftentimes in these studies, they'll categorize people as like normal overweight obese. But as we've talked about on the show many times, there's actually a huge gradation within fat people. Like you're talking about people that are like 210 pounds and you're talking about people that are like 600 pounds. That's a huge category, right? And so oftentimes what you find in these studies is they'll say overweight people are fine, but like obese people, that's where all the risk is. But then what Catherine notices once you start digging into their data, if you break up

the fat people into like, they call it again, these names, they call it class one, class two, and class three obesity, the lowest class of obesity, like the thinnest fat people, oftentimes also, don't really have any health risks. So for her previous study, she found that if you're 5'8", up to 185 pounds, you don't really have any health risk. In this study, which is even bigger and has more data, you can go up to 210 pounds, and still not really have any elevated health risk. Right, I mean, this is where it feels worthwhile to insert that until the late 90s,

people who are now in class one obesity category were previously in overweight categories, and people who are now in overweight categories used to be in quote unquote normal weight categories. Oh, it's so fake, dude. It's so fake. It's so fucking fake. Also, one of the things that's amazing in, because I've read a bunch of these

like random ass studies for this too, one of the things that's incredible is they'll mention like almost like off hand. They'll be like, oh yeah, BMI for black people just like doesn't work. Like some of them will be like up to like BMI of 35. You can weigh like 280 pounds if you're black and like not have any of these mortality statistics.

But some of them have also found that like, it just doesn't fucking matter for black people at all. And it's, again, treated as this weird footnote. Oh, it's a paradox. No reason to dwell on it. No reason to put it in the abstract. No reason to write an open letter or anything. Anyway, back to the main event. Anyway, white people.

Jesus fucking Christ. This is the fucking chickens coming home to roost when you made a like body measurement slash eventually like moral assessment tool that was only built for white people. So basically this massive meta-analysis finds the same thing that her previous study found and that lots of other studies around the world have found this like basic mechanism. And again, Walter Willett goes on the attack. He shows up on NPR and says this study is a pile of

rubbish and no one should waste their time reading it. Wait, is that a quote? Oh yeah. Oh, Jesus Christ. He also tells, I believe, the Atlantic. He's like, Kathy Fleagle just doesn't get it. And then Catherine's like, I go, my Catherine. Don't, don't, let's just keep it Catherine Walter. That's as close as you'll get in like academic research world to like get my name out of your mouth. Sfully like Smackdown. Like, which it's great. So speaking of unfair criticism, I'm going to be very unfair to Walter right now. So he gave, because he calls all these journalists and inserts himself in all of these publications about this controversy, there's quotes from him everywhere.

And so I made this little medley of all of the inappropriate shit that he says about Catherine doing this period. And so I am gonna send it to you to read. Okay, quote, when Willet sees the CDC study on obesity, his mind flashes to the picture of what he is sure this confusion will lead to.

Patients packing on more weight while their doctors become less willing to broach the subject. People will get fatter, die sooner, and all the medical bills could cripple the healthcare system. Willet feels he has no choice but to go on the attack? No choice. It's important to push back strongly against the promotion of ideas and analyses that are based on faulty data, he says. Will it claims that Flegal clearly has a point of view on this issue? After all, she published a paper in 2005 that reached the same conclusion about the protective powers of a few extra pounds. Quote,

The Fleeful Paper was so flawed, so misleading, and so confusing to so many people, we thought it really would be important to dig down more deeply, will it says? Studies such as Fleegles are dangerous will it says because they could confuse the public and doctors and undermine public policies to curb rising obesity rates. According to Willet, the paper's legal published were woefully misleading and undermined dietary guidelines that had been in place for several decades. Worse, he says, these findings can be hijacked by powerful special interest groups, such as the soft drink and food lobbies to influence policy makers.

Quote, it's basically giving a green light to gaining weight and becoming overweight. We're talking about millions of lives lost every year due to obesity. It's a death spiral as this gets normalized as we look around and everyone's overweight." End quote. So other than agreeing wholeheartedly, what do you think?

Um, I mean, this is, so like, here's what I think about this. This is genuinely the shit that trolls say online all the fucking time. It's wild, right? This is the shit, right? And actually, like, I genuinely don't even know where to fucking start with this. Like, oh no, this would undermine public policies

to curb rising obesity rates, which don't fucking work. I know, exactly. We've been doing for 20 years and have produced nothing but continually rising obesity rates. Like, oh no, they go against dietary guidelines, which change every five to 10 fucking years, because we know very little about nutrition all told. Won't someone think of the dietary guidelines?

Everyone, the beloved dietary guidelines in all Americans know and love and never change. Yes. I can't jump inside his head. I don't know what he's thinking. What this communicates to me as a fat person and what I hear with this stuff is like the ultimate terrible thing that will happen

as a result of this is that there will be slightly more people who look a little bit more like me. I know. I also think an important thing that he says here is that he says, you know, all this is gonna undermine public health. And also, it's gonna be taken up by powerful lobbies of like the soft drink makers

and like the fast food companies. And on some level, he's actually right. There are like really gross corporate lobbying firms like these fake grassroots companies like that pretend to be grassroots NGOs, that like say the same shit that we do. Yeah. I sort of get that like, yeah,

there's some really gross forces aligned with like what we are saying on the show, like that is worth acknowledging, but also his argument is aligned with pharmaceutical companies and the weight loss industry. Right. You're not like the lone David standing up to like the gath of McDonald's.

It's like you're sitting there with Novo Nordisk, dude. Yeah, totally. Well, and also just like, listen, corporations are going to use whatever the fuck is in their reach to prove their point. Yes. And that can't and shouldn't drive what research tells us, right? Exactly. So like his argument, I would say, is like even more dystopian, which is like,

we shouldn't research anything that corporations could then turn around and use to defend their own self-interest and their own bottom line. That's also not good. That's also corporations in their way. Exactly. An undue influence on science and research that we shouldn't be encouraging, dude. Exactly. It just feels like deeply, not only half baked, but it's like leading him in like unintentionally a more sinister direction. I don't know. I mean, when I talk to Catherine,

like I think this was what really bothered her is that he's basically accusing her of like having ideological motives with no evidence. Right. There's one report of someone who was in a class of his and he said that she holds these views, she publishes studies because she's a little bit plump herself.

Oh, get fucked. Exactly. So look, this is a person on Twitter, this has not been confirmed. I want to be clear about the source of this information. Right. But what bothers me is even if that isn't true, what he's accusing her of is basically being an idealog, right?

That like she wants a policy outcome, she wants doctors to not talk to their patients. And like he is skipping straight from the data to the implications of the data and accusing her of trying to bring about some sort of policy outcome. And Catherine Fliegel, like I don't know much about her, she's actually kept her personal life completely out of the public sphere, which seems totally fine to me.

But even in our phone call, she would correct me. If I was like, yeah, I feel uncomfortable with doctors talking to patients about their weight. She'd be like, well, I don't know about that. My study is about mortality rates. All I'm talking about is mortality rates. I don't really know what the implication of that is. I don't know what the policies should be.

She's always been somebody that's like extremely temperate about everything she says. And like, I've seen other interviews with her, like you cannot get her to go beyond the data. Right. And then we have Walter Willett, who's written four diet books. Right, he has told reporters from like every outlet in America

that he thinks that it is dangerous to be fat and he thinks that it is irresponsible to publish scientific research that even hints at the idea that it might not be as bad to be fat as he thinks. And it's like, who's acting ideological here? This is also such like every bad faith dude who I've ever worked with, who just sort of covers his weight around. Both, this is a totally extraordinary story of science getting hijacked by like weird personal interactions and personal motives.

And also it feels totally unremarkable and common force. And like all of us, especially any of us who are not white dudes dudes like know this fucking dude Dude, I know I love that it's like this is an outrage and also Wednesday And also staff meeting It's so remarkable and it's so not all at once exactly and for like all of my close friends and family I can name you three of these dudes in their lives. Yeah, I have known those dudes and I've also been that dude sometimes.

Oh, Michael. No. The bravery. Congratulations at me. Congratulations at me for admitting it. That's what I want. I'm an amazing you one cookie. Thank you. That's all I want. I don't have to actually fix my behavior as long as I acknowledge it. Oh, man. That's very good. Okay, are you ready for the methodology queen section of this episode? I've never been right here, Mike. So I've been saving this because a lot of the arguments that Walter makes against Catherine are like technical, methodological things about how she has designed to this study and I want to take them seriously. So what he says in his article that he eventually publishes like responding to her study is he says,

we believe her study is flawed. Their normal weight group contains persons who are lean and active, heavy smokers, frail and elderly and seriously ill with weight loss due to their disease. So he's making a specific point about her sampling. He also says, he also says, as well as Asian populations, historically undernourished and burdened by infectious diseases. What the fuck? Because I think she included some data sets

from South Korea or Japan. What do you do, exter? Walter, we're talking about human biology, Walter, and it's a normal thing to include studies from other countries when you're doing that. I also like that he was like, hmm, my take doesn't seem garbage enough. Put some sprinkles on that, that has no sprinkles.

Bird and by under nourishment, like what the fuck man? So he has a couple, there's a lot we have to unpack here. The first argument that he levies against Catherine Fletchle's work is the problem of smoking. This is a real problem in these studies that like if you leave the smokers in, it ends up fucking with your mortality rates all over the place because like smoking is so bad. Like there's statistical methods for sort of getting rid of smoking and making everybody comparable across groups. But Walter thinks that that is not enough.

So what Walter points out is that in the skinny group, right? The reason why you have this weird spike among skinny people, like skinny people have really high mortality, the reason for that is because there's just like way more smokers in that group. What?

Because smoking makes you skinny. They're not at higher risk because they're thin. They're at higher risk because they're smokers. So you have to remove all the smokers and then you'll get cleaner data. Oh, Jesus. Instead he does, he removes all of the current smokers and everyone who has ever smoked.

Great, cool. That's how human health works. You can just remove an entire crack. I don't know, man. It just, ugh. So yeah, a couple problems with this. First of all, current and former smokers is 40% of the population.

Ha ha ha ha. So you're removing 40% of people from your analysis. Yeah, they don't count. There's also this huge problem with the category of former smokers. Because like my grandma is a former smoker. She's smoked for like two years. When she was, I think in her 30s and now she's 97.

Right. But also like there's also former smokers that smoke like a pack a day for like 50 years. So it's like the group of former smokers, it's not clear what effect that is having on their health or their weight But you're just removing all of them as if like it's so contaminated that you can't look at them at all Also as you have noted that's like basically like disproportionately removing poor people

Exactly. It's disproportionately removing like a bunch of marginalized communities and again feels like a likely return to communities and again, feels like a likely return to centering the bodies of like middle-class white people. Right, like if we're like getting down to it. Well, this is the problem, is that what you end up doing with removing all the smokers is you say that you're removing the effect of smoking. Right, you're like, you want cleaner data. But what you're actually doing is you're removing a bunch of poor, uninsured, unhealthy, thin people, right?

Because smokers are disproportionately thin, and you're leaving in all the fat people that have those bad health outcomes. Right, you're just removing all the sick thin people and leaving the sick fat people. Right. It's a... it... oh god. I don't even... like I'm so fucking tired. I like... I was about to say something about how like, yeah, heaven forbid we have like actionable public health research that works for people who live at or below the poverty line. But then I was just like, I'm fucking tired.

It's all such a racket. I know. Great, so you're reverse engineering everything, so we're just researching you and then all of our public health mandates just come from people who live the kind of life that you live and they keep fucking only working for people who already have a lot of like wealth and privilege then fucking what? Yeah, so the second thing that he says is contaminating her work is that she's not removing

sick people. Oh, so the idea basically is that like the reason why you have these higher death rates among super skinny people isn't because they're like super skinny people that like post photos of themselves in bikinis. They're old people who are like wasting away from some sort of pre-existing disease. So like my grandfather died of Parkinson's and like in his last two, three years of life, like yeah, I think he weighed like 85 pounds when he died. In the data, he would count as a death among someone with a BMI of like something like 17 or something that has nothing to do with his weight.

It has to do with the fact that he has this pre-existing illness that first made him thin and then killed him, right? So the spike in mortality among thin people is because you're packing in all these people that have like all kinds of diseases, right? Like various cancers leukemia. If you're in the late stages of a disease, you're going to have a very high mortality rate and you're going to be very thin. And that also affects the normal weight category. And even that slightly higher weights, you still have all these people that basically have like wasting away due to disease. Right. That's what I was going

to say is like, couldn't you say the same thing about like someone my size wasting away quote unquote could mean a loss of a hundred pounds for me, right? Like that would be like dramatic weight loss. I would still be in the quote unquote obese category. Well, this is the whole problem, right? I think it's, it's so interesting once you start talking to people about the higher rates of mortality among thin people.

Thin people are very likely to die according to these studies and then you watch people's minds go to like, well, that's not because they're thin, right? It's probably because they have an illness. Maybe they have a release of your eating disorder or something like that. You know, there's all these conditions that make you thin and then kill you

and it's like wait until I tell you about fat people. Yeah, there's also these conditions that make you thin and then kill you and it's like, wait until I tell you about fat people. Yeah. There's also medical conditions that make you fat. What? Do you know how many medications cause people to gain weight? I think birth control pills, it's typically 15 pounds. There's mental illness medications that cause you to gain like 50 pounds.

And like oftentimes those people have higher mortality rates too. So it's like, the same thing is happening on the other end of the scale. Right, there are also health conditions like lipidema, which is like swelling and like accumulation of fat in specific parts of bodies. If we're cutting people out and going, okay, it doesn't apply to this person,

it doesn't apply to this kind of person, it doesn't apply to this health condition. It seems fully fucking bananas to do research on fat mortality and not account for things like polycystic ovarian syndrome, not account for things like eating disorders at any level. Exactly. I mean, this is so fascinating to me to watch people

explain away the higher mortality rates among thin people. They're like, well, it's complicated. But it's not for fat people. Yeah, so it's like, okay, obviously every fat person needs to lose weight because they're at like a, you know, 40% higher mortality risk, but why don't thin people need to gain weight? It's like, oh, well, because it's complicated.

It's like, well, it's the same data. It's literally the same table of the same study is saying that like these two groups have elevated mortality and you're prescribing a change in weight for one of those groups and not for the other group. Like that to me is so revealing. It's like, oh, the thin people, like, oh,

this is a real mystery that we need to get to the heart of. Okay, it's also kind of a mystery with the fat people too. Yeah, guess what? Even knowing that and even noticing this pattern so frequently, so commonly that people will bend over backwards to talk about why being thin is always healthier than being fat and being fat is always less healthy than being thin.

You're just like, well, there's your bias and that still doesn't actually change anything in the mindset or behaviors of the person who's doing it. So it's like really fucking frustrating as a fat person to see and hear these conversations happening all the time and see and hear people just like showing their entire ass. Dude, yeah, it's like, look, we don't, we don't want to strip thin people of all of their humanity. Like, let's figure this out before we prescribe anything.

Like, wait a minute. Hey, thin people are more than a number, dude. Like, yeah, fucking, so are fat people. What the fuck? So like, Walter in his studies recommends removing everybody who dies within the first five years after their heightened weight are taken. What?

He also says that after people are diagnosed with an illness, they, quote, might become motivated for the first time to lose weight. Fuck off. Finally, a recent lose weight. Oh, good. What a good motivation is your mortality. What the fuck man? It's worth noting, there's no actual evidence for anything that he is saying. So, Captain Flegal writes like a very salty methodology paper about this that first of all, the number of people who are like wasting away like my grandfather with Parkinson's is like actually pretty small

Yeah, but people in like the late stages of a disease and also those people are not very likely to answer a survey for a longevity study Mm-hmm. They're not really contaminating your data all that much and then this thing of like removing everyone Who dies in the first five years, like you can actually check who are you removing, and when you remove people, you're mostly removing fat people. Walter is saying that you have to do this

to remove all these like sixth in people, but then you actually end up removing a bunch of fat people, and of course, Katherine runs the numbers on a bunch of these studies, and it's like when you do this, you just raise the mortality rates for fat people Right intentionally or not. It's juke-ing the stats basically exactly

He talks about how you have to remove everybody with these pre-existing conditions because they might be losing weight And then eventually die due to those conditions But there's just as many Conditions where people gain weight after diagnosis. It's very typical for people to gain weight after their diagnosis with diabetes because you start taking insulin and it spikes your appetite. There's a lot of other conditions

that you gain weight once you're diagnosed because you get on medication and you start getting better. So this idea that we have to exclude everybody who has a medical diagnosis because they're becoming thinner, it just isn't true. Right, you start winnowing out, like, okay, we can't count the smokers

and then we can't count people who were previously smokers and then we can't count people who've had cancer or Parkinson's. And then also now we can't count people who have mental illnesses and have been treated for those, but we can include the people who haven't been treated for like, exactly. And we're like who haven't been treated for it. Exactly. We're just like, what the fuck is this weird ass patchwork

that we're coming up with here? And also, this is like, after you do all of these exclusions, right, you're excluding everybody with a preexisting condition, everybody who's ever smoked, and everybody who dies within the first five years, Catherine finds a bunch of articles that were written by Walter and his colleagues where they're removing 90% of the deaths. What? 90% of the data is gone.

Yeah, fucked. The central gas lightiness of these statistical methods is that like they are doing this to remove bias. Officially, right? They're like, well, Catherine Flegal's numbers are biased because she left all these people in. And she's like, punk, you're removing 90% of the people, and then you're going to tell me, they're like, it's less biased. Right. And like, does this look like the US population at all? People who've never smoked, people with no pre-existing conditions? Right. Again, this is a place where it would be helpful to start the conversation, not from a place of

Is research biased or is it not? But where does bias lie in all research that we have? Exactly. So like among the population around 40% of people die to something related to cardiovascular disease like 40% of deaths in the US But then when she looks at these samples that they're using, only 20% of the deaths are due to cardiovascular disease. This isn't a normal pattern. Part of the reason why it's so hard to get to this fucking number is something that it feels like none of the data is really like engaging with. It turns out fat people have other health conditions and so do thin people than just the

size of their fucking bodies. There's like lots and lots of factors that impact people's health that are beyond this bizarre world that so much of the research wants to imagine, which is just like a bunch of fat people started out as thin people and then just decided to keep eating. And we're just gonna measure the impact of that on their health.

The number of assumptions built into that are astonishing. I mean, this gets us to like the final chapter of the story, which is basically none of this shit matters. Yeah, I'm just gonna go ahead and undermine everything we've already talked about. So it's now 2016, Catherine ends up resigning from the CDC, she's now at Stanford. Walter meanwhile has basically put together this entire

like consortium of I think it's like 500 researchers or something like that like this big global BMI collaboration, basically just two debunk Catherine's work. So he publishes in 2016 this like massive study that he says is like to settle the debate. Her meta analysis had like three million people in it. His meta-analysis has like 10 million people in it. Okay. And it's like, all right, Catherine, this is it, the final word on obesity and health

and they published this study and wouldn't you know it? Normal weight people have the lowest mortality and then overweight people have more and then obese people have like even more. Yeah. Sorry, Catherine, that's just the science. I do like the idea that the dude who started this whole weird quote unquote debate that really just seems like an attempt to torpedo this lady's credibility

is like, guys, I got it. I'm gonna settle the debate that I started. Like, no, okay. I also love that in this study, even all of the manipulations that I started. Like, we're like, no, okay. I also love that in this study, even all of the manipulations that we'll get into, thin people are still more likely to die. Yeah, he wasn't able to get rid of that. There it is.

The funny is fucking thing about this is that he's like captain methodology. Like I am so disappointed with Catherine's methods, right? And this study is fucking garbage. Ooh! Catherine legal writes like a series of responses that are like some of those scathing, like in academic language,

but like very scathing language about how bad this study is. So first of all, his whole thing is, of course, like he wants to remove, like everyone with a pre-existing illness, everyone who's ever smoked, et cetera. The problem is, among these studies that he's looking at, there's 239 studies that they're looking at, only 28 of them even have

data on people with pre-existing diseases. So he's like, how dare Catherine Flegal not remove these people. And she's like, only a tiny bit of your data allows you to remove those people. So functionally, you're leaving them in two. And then my favorite shit is that in all of their analyses of North America, because it's a global study, 94% of the deaths came from studies with self-reported weight. And the other thing I got totally obsessed with is that in this study, Walter is cutting out everybody who dies in the first five years. And he says that you have to do this to make your data clean, and anybody who doesn't do this is publishing flawed, naive, misleading data, whatever.

The question I kept coming back to is like, well, wait a minute, why five years? Why not four years? Why not two years? And when Catherine looks into this, Walter Willett himself has published studies that cut out everybody who died in the first four years. A lot of his co-authors on this same study have published data where they cut out people who die in the first two years. So, it's like, ex-istentially important to do this because it totally contaminates your

data, but you yourself are not doing it consistently. Like, it's weird to me that we're all supposed to see it as some sort of coincidence that he happens to choose the methodologies that produce the highest mortality rates for fat people. Like, we're all supposed to look at this and be like, oh, well, all he's doing is what he considers in a content neutral way to be the best methodology

for these studies. And, ah, would you look at that? This aligns with exactly the policy preferences that he has been telling NPR reporters and everybody else who will listen in public. He thinks that it is dangerous for you to be fat. He thinks that you should weigh what you weighed when you were 20.

And he happens to believe total coincidence that the methodologies that produce that result are the right methodologies. It just all reads to me as people grasping at straws to justify what they already believe. Yes. There's a little bit of an imperfect parallel, but a parallel to journalism and the idea of objectivity and journalism, right? Yeah. Scientifically, we know that like, objectivity doesn't actually exist, right? That all of us are influenced by cultural biases, all of the time, implicit or explicit. So like, what would it look like to build journalism or build research around acknowledging those

biases and working to counterbalance them? Rather than insisting that they don't exist and still doing what you were going to do anyway? I mean, this is the whole thing. I mean, this is like my grand conclusion, like what I want to end with. It's important to break this whole dilemma into two separate parts. So for the vast majority of people who are in either the overweight category or like class one obesity, like low grade fat people, that's like the majority of the people were really talking about in America.

And like the relative risk mortality ratios, they're so fucking small. If you even in like the Walter Willett like p hacked within an inch of its life study, it's like 40% higher for like grade one obesity, I think. Again, unmarried people have a 230% increased mortality rate. Guys, I'm going to die because I'm single, not because I'm fat. This is the thing. In these like fake stupid categories of like overweight and class one obesity, the mortality risk rates are so weird and like tiny and conditional

on these weird statistical methods at those weights. That like, I honestly just think that like, it's bullshit to tell somebody in those categories that like they must lose weight. Like the data does not support that, I think, straightforwardly. Right. And then there are these categories of much fatter people.

Once you get into BMI's above like 35 or 40, it's like somewhere between like two and five percent of Americans. Very consistent correlations that like those people have like very elevated mortality rates. They have much higher rates of heart disease. Like I'm not going to deny that. Like those correlations are extremely consistent. But then the question with much fatter people is, first of all, what is causing them? And second of all, what do we do about it?

Yes, it's a small number of people. It's me. I'm in that category. Hi, everybody. Hello. I'm in that category. And that 2% to 5% of people are people who are already facing, like, untold levels of stigma.

Yes. We are being encouraged at every turn to treat that group of people like shit. So like bad faith actors start to fucking activate and form like whatever they're like Voltron, Shitty, anti-fat shit. Yeah. This is already a group of people

who are getting shit on left, right, and center. Exactly. If we go to those people, when you look at those statistics, it's dire. It's like their half is likely to be college graduates. One quarter of them are earning less than $20,000 per year. Their twice is likely to be on Medicaid. The group with the highest prevalence of grade three obesity is black women who didn't complete high school. Yeah, there it is. Is this a group that like we're confident in saying,

it's the weight that's doing this and that like what they need is to lose weight? Yeah, is that the biggest need that we've identified here? Also, have we listened to poor fat black women about what they want and need? Exactly. Instead, we're focused on chiding fat people

for what we assume their behaviors are. There's all kinds of studies on fat people do not get pap smears. Fat people do not get prostate cancer checks. If you wanna say that it's the adipose tissue that is causing those health consequences, you know what, fine. I'm probably not gonna talk you out of that opinion,

but it's like, what can we do? What are the steps that we can take for that group? They will actually make a difference because telling them to lose weight, we know that it doesn't work. Medical institutions define successful weight loss as losing 10% of your body weight. So if you're 300 pounds, you're gonna be a 270 pound person.

That's the best we can deliver and not even very reliably, but there are some programs that have been shown to deliver that for some number of people, great. We now have a 270 pound person. What does that person need? Right, the idea that any of this data doesn't account for medical bias

and the ways in which doctors will diagnose illnesses differently, the ways in which doctors will and healthcare providers of all stripes will have like shorter visits with fat people, they'll order fewer tests, they'll consider fewer options, and then fat people understandably will post-pone healthcare as long as they possibly can.

I have a family friend who was like, put on prednisone by her doctor and put on weight, because that's what happens when you go on prednisone, right? This is one of many medications where this happens and is now having significant, significant cardiovascular issues and her doctor is saying, well, it's cause you didn't lose weight and you need to lose weight. And she's like, I need to go into the hospital.

These are like very clear cut cases of fat people clearly not getting the care that thin people are getting. It just feels utterly bananas that we have a cultural conversation that is dominated by thin people and thin people's imagining of fat people's health and not the like extremely overwhelming, very clear experiences of fat people on this front. One of the things I found in one of the older papers, one of the few papers actually that

actually investigated the causes of death among fat people, like cancer deaths are much higher among fat people. This is like a pretty well established thing, but they noticed that one of the reasons for that was that fat people couldn't fit into the machines that they needed. They also, a really interesting one, was they mentioned that fat people were much more likely to get gallstones. It's some sort of side-effective, like what you're eating, but when you look into gallstones,

it's also a side-effect of dieting. But if you stop, especially fat consumption, but calorie consumption, your liver just goes nuts. It's like 30% of people who get gastric bypass surgery and stop eating very quickly, they get gallstones, 30%. So it's like another one of those things that is like, it's seen as like, well, fat people

are at higher risk of gallstones and like, okay, but is it the fact doing that? Is it their diet or is it dieting? And those are actually like very different phenomena as a society that we would need to look into. Quite a bit of the things that we think of as being like the cost of being fat are actually the costs of weight cycling, right?

Oh my God. Guess who's under the greatest pressure to diet all the fucking time? Surprise, it's fat people. Again, like there are so many confounding factors and the fact that we spend zero time talking about any of them feels like a real tell. Wait, can I read you something?

Yes. Okay. So I do think that the effect of dieting and people basically being in a starvation state for potentially years is vastly undercovered. Yes. But the studies are trash. Oh really?

Oh my god, a lot of them are on fucking rats, and they do show that like raising and lowering their rats weight is like really bad for them. It's like fine, but also rat studies. A lot of them are just slicing and dicing the same data and like people aren't gathering weight cycling data. So like these big cohort studies, one of the huge weaknesses of them is you're relying on like what were they asking people in like the 1990s? You can't go back and ask people the same questions. So they're using the data that they have. So I found it a study on weight cycling, like a study that shows that weight cycling is bad, but look at this fucking methodology. So they're looking only at men, of course,

because these cohorts are terrible. Strong start. Exactly. So it says, at the time of their first examination, these men were asked to recall their weights at age 20, 25, 30, 35, and 40. I know, I knew you love this. Weight cycling was defined as a gain of 10% of body weight in one five-year interval and a loss of 10% in another five-year interval. What? That's not how weight cycling works. My mom weight-cycled my entire fucking upbringing. Yes. It was not on five-year cycles, dude.

It was on like three months, one year. Your mom and like many, many, many moms. You're right, like, oh, the moms. This is what's so fascinating to me is like, there's so little interest in figuring out any explanation for these health conditions other than obesity. Yeah, there is also like, I would imagine

a pretty significant impact on the health of people who engage in very severe dieting, but don't meet that definition of weight cycling. Exactly. Or that don't lose or gain weight particularly at all. Exactly, that's the thing. You know, and we've talked on the show about people can be 250 pounds and eating so little that they're not getting their period.

There's lots of people that are at some version of that, at some level of a starvation state in their body, and just maintaining that for years. So they wouldn't show up in the study. I'd just say it again, there's not a single method of weight loss that is nonsurgical that meets the standards of being an evidence-based treatment. Exactly.

So like, what the fuck are we doing here? If we're all, if all of our research that we're conducting is reverse engineered to lead back to the same fucking mandate about weight loss, why are we doing that if we don't know how to produce weight loss? And frankly, even if we did know how to make people lose weight, it is intensely troubling that we have massive societal institutions that are all geared toward forcing people to look one way and to have one kind of body. That's fucking terrifying. So can we end with like a little epilogue?

Yes, please. So in 2021, Katherine Flegal wrote a article about like all of this. That is where all of this is coming from. This chronological retelling of like, I did this work. And this guy Walter Willett was like a real weirdo about it. Yeah. Walter has always been like totally clear that like he regrets nothing So when he was contacted by journalists after Catherine wrote this essay

He said and I quote her description is mostly correct and she shouldn't have been surprised I did describe her paper as rubbish and I do stand by it. Wow The captain's going down with the ship. Just like, she says it really stuff the way that I treated her and like I feel fine about it. Wow. You know what, your paper was bad. Yep, she's right.

I did it. I do it again. So I have been trying for a couple of weeks to get an interview with Walter Willett because I feel like if I'm going to be me and you on a podcast, like I should give you a chance to respond. Yeah. We scheduled one and then he had to cancel something moved around. But then he said, look, sorry, I had to cancel our interview, but I've written a response to Catherine Flegal and like, here it is.

The response is called evidence does not support benefit of being overweight on mortality. So just like right back to like, she's wrong. Backed square one. So he says her meta analysis did not deal adequately with the fact that smokers have lower BMI's, but high mortality. Oh. And it's like Walter, the whole debate was about whether

this was an adequate way to deal with that. Right. That's the debate, Walter. Yeah. On the one hand, I appreciate his like street, straight forwardness of just being like, yeah, I fucking did it. I did. What about it?

She sucks. Yeah. She sucks. She's, she's right. I did say that she sucks. I do believe that she sucks. And on the other hand, it feels so disingenuous to be like, actually, this debate was about this other thing where I'm like, no, what fucking wasn't.

And it's all writing. What are you doing? He also says that his 2016 garbage paper firmly refuted her own work, which like, no, it's all writing, what are you doing? He also says that his 2016 garbage paper firmly refuted her own work, which like, no, it's just you did it differently than she did. He also says, this is my favorite line. He says, these are not statistical issues,

but rather the reality of human biology and require detailed analyses that could not be conducted in a meta analysis of previously published data. Good. Walter, you also did a meta analysis that was based on previously published data. Like, you're now against meta-analyses? It's real wild that there's like no engagement

with the substance of the critique here. It's incredible. There's no point at which he feels, he appears to feel compelled to defend his own methodology. Exactly. He just goes back to, anyway, she sucks and I'm right. Exactly. Right, but I'm like, what?

I have drafted an email to him so many times because he emailed me this paper and I read it like a gogg. Yeah. I wanted to be like, Walter, do you not, do you not see it? This, you're not see it? You're not engaging with this debate at all

or even acknowledging that it's a debate. Right, it is, I imagine reading that email was not unlike reading the one sense where they're like, we just assumed every fat person that I do fat, where you're like, you just fucking said it and published it. And then the one thing, we're like, this science is good.

Like what? I don't want to both sides of this and say that they're both doing the same thing and published it in the middle of a day. And then the people were like, this science is good. Like what? Ugh. I don't want to both sides of this and say that like they're both doing the same thing. Cause I think Walter Willett is like much worse and what he's doing is like less methodologically defensible.

But also, Catherine Flegal is probably also guided by bias in this too. The process of making science is a series of judgment calls. And there's nothing wrong with that. There is a very strong association between fat people and worse health outcomes. But I think we have been told a specific way to interpret that for most of our lives.

And I don't think that we've been told all of the judgment calls that made that conclusion. Yes, and if you're creating all this research, if you're creating this industry around reducing the number of fat people, this is what Alicia Monday calls obesity ink. You are going to be training generations of healthcare providers in reinforcing their existing cultural biases using science, right?

Right. So it's like introducing this incredibly moralizing view of patients who have no choice but to trust you or just not get healthcare. And that's like part of what's happening with fat people, right? Yes, oh yeah. And also, I mean, the whole idea of boiling somebody down to their like statistical mortality risk,

that's a gross thing to do regardless. Like I have had this conversation with so many people where I'm like, yeah, you probably should just like not treat people according to like what you think their, you know, health risks are. I don't go around like scolding smokers. And then every once in a while, you'll get people who are like, well, I do scold smokers.

I do, I do. Smokers, and it's like, congratulations on like being a weird dick. Like great, good for you. Yeah, I mean like genuinely like all of this shit about like, I'm concerned about your health, all of this shit about like I'm concerned about your health, all of this shit about burdening health care systems, all of this stuff to me as a fat person reads

as a fig leaf for I want to talk about how uncomfortable I am with fat people and how much I just like them and how much they gross me out and how much I don't wanna be fat and all of these other things that are not even remotely related to the health of people. Yeah. Yeah. It's not like people learned about the population level hazard ratios of adipose tissue and then decided to dislike fat people. It seems extremely

obvious that people disliked fat people and then went looking for the hazard ratios. They were looking for a reason. It's such a challenging thing to have people doing all this shit in the name of quote unquote the science, and then when you look at quote unquote the science, it's like very human, very flawed, very unreliable, and very disputed. And also the science is pretty clear that like being mean

to people is like bad for them. Right, crystal clear. It's crystal clear that being being mean to people is like bad for them? Right, crystal clear. It's crystal clear that being a dick to people is bad for everybody's health. So maybe knock that shit off. But how bad, Aubrey, I need to, I need to cohort. Find me 70,000 nurses. What? Thank you.

Thank you.