TCS Daily

'Medicalizing and Moralizing Matters of Fashion'

By Nick Schulz - May 27, 2005 12:00 AM

Editor's note: Paul Campos is the author of a new book released this month, "The Diet Myth: Why America's Obsession with Weight Is Hazardous to Your Health," an update of his 2004 book The Obesity Myth." Campos is a Professor of Law at the University of Colorado and he recently sat down with TCS editor Nick Schulz to discuss public health, the war on fat, moral panics and 'medicalizing and moralizing matters of fashion."

Schulz: Paul, thanks for speaking with us. The Centers for Disease Control recently reported that the earlier numbers, they have been touting, claiming that obesity was responsible for anywhere in the vicinity of 300,000 or 400,000 deaths a year, those numbers were grossly exaggerated. Did the CDC's revision surprised you and if not, why not?

Campos: Well in one sense, the revision didn't surprise me. It didn't surprise me in the sense that if they were actually going to do an accurate and honest evaluation of the epidemiological literature, there was no way that the earlier 300,000 figure from 1998 or the 410,000 figure from 2004 could stand up to scrutiny.

The epidemiology on this issue is extremely extensive and what it shows is that there is no significant difference in relative risks or early mortality between the so called normal or ideal weight category on the one hand and the so called overweight category on the other. When you look at the obese category you do not begin to see significant increases in relative risk until you start getting to really high levels of obesity. What's more, you see similar levels of relative risk associated with only slight amounts of so called underweight that are similar to what you see with very high levels of obesity.

Schulz: Dr. Paul Ernsberger said in the foreword to your book that there is a, "wave of hysteria surrounding obesity in the US." Do you agree with that?

Paul Campos: Absolutely. I think what we are seeing is what is called a "moral panic." That is, we are seeing a fixation on a particular risk that is out of all proportions to the actual significance of the risk with a projection of the risk out on to a certain group of people who can be blamed in a fashion which, in the sociological literature, is described as a folk devil, essentially.

And that's I think, what we are seeing with overweight and obesity. There are all of these claims that have been made with increasing intensity over the course of the last few years that overweight and obesity are causing some sort of massive health crisis in the United States.

There's really no evidence for this at all. And if you look at the overall epidemiological picture and the overall public health picture, as a lot of people and skeptical journalists, thankfully, are beginning to do, you see that, in fact, overall health in the United States is better now than it has ever been before; not only is life expectancy longer than it's ever been before, but morbidity, in terms of all of the major killers, is down.

We may have lower rates of heart disease and hypertension than we did a generation ago. We have lower rates of cancer. Diabetes -- despite the constant claims that we hear about a diabetes explosion -- the rate of the adult onset diabetes or Type-2 diabetes -- appears to be basically constant. It has not really increased over the course of the last 10 to 15 years.

Nick Schulz: But there's certainly evidence that people have been getting heavier in recent years and decades. What in your estimation accounts for this increase in waist lines?

Paul Campos: Well, this is a very complex question, and one of the false claims that tends to be made is that we know what's causing this. We really don't, actually. We don't have good data on this. All we have are hypotheses, essentially.

For what it's worth, I think a big factor, and one that is often ignored, is a decline in smoking rate. And we've seen a drastic decline in smoking rate that's sort of basically been cut in half among adults over the course of the last 35-40 years. And I think this is probably a significant causal factor in terms of the weight gain that we see in the population.

How much of the rest of it is due to increased caloric intake or decreased activity levels? Again, we just really don't have a good sense as to what relation there is among these different factors.

And probably, some increase in sedentariness is a factor, although this is actually quite difficult to measure.

It's not because people used to be virtuous and now they're not, which is one of the classic means that people use to account for why things are supposedly worse than they used to be.

What I'd emphasize here is that if you actually look at the median weight gain in the population over the course of the last generation, it's probably been about eight pounds. The mean is higher than that because you have some real significant weight gain at the far right end of the tail of the bell curve. But the median is probably only about eight pounds or so. Such a weight gain, when you look at the actual epidemiological data, has absolutely no significance in terms of increasing relative risk for either mortality or morbidity in a way that any epidemiologist would ever pay any attention to it.

Nick Schulz: We hear a lot about in this debate about the BMI. And I'm wondering if you can explain quickly what the BMI is. And then if you think it's a useful tool for better understanding about individual health and public health or do you think there are problems with BMI?

Paul Campos: The BMI, which stands for Body Mass Index, is a simple mathematical formula whose purpose is to put people of different heights and weights on a single linear scale.

In other words, you are able to look at, say, a five foot four inch and a six foot two inch person and say that relative to their heights they weigh the same.

It was actually invented by a French mathematician in the 19th Century for that purpose. Its limitation is that, except for real statistical extremes, somebody's body mass doesn't actually really have any -- or only very minimal -- significance in regard to any kind of predicted statement about their health or their mortality risk.

What we've done in this culture is taken a really quite narrow range of the natural, somewhat changing, but relatively stable distribution of body mass that you will find in any developed economy's population, and we have arbitrarily labeled that narrow range as "normal," which it certainly isn't in any statistical sense, or "ideal," which it certainly isn't in any epidemiological sense.

That's one of the things people don't appreciate about this phenomenon. It's not that this is somehow, in any way, limited to the United States. If you look at any developed economy, roughly half the population or more is "overweight." Nations in Western Europe have the same average BMI or even higher than we have in the United States.

Nick Schulz: Most people will be surprised to know that.

Paul Campos: Yeah. It comes as a big surprise because there's this assumption that always, because Americans, we are so lazy and...

Nick Schulz: Their car culture --

Paul Campos: Right. You know, it's really one of those things that is a product of powerful social myths that are not very amenable to reason. Because by any objective criteria, the notion that Americans are lazy people in comparison to the rest of the world is a kind of crazy notion. But it's one that is constantly being reiterated in this context.

I really think that what's fueling this on a basic level are these anxieties about decadence and over-consumption and laziness and that somehow we've got something wrong with ourselves as a nation. And this is always being projected out on to this matter of weight.

Nick Schulz: So in that sense the concerns over obesity are not really questions of science or health or data but are really reflections of value judgments and aesthetic judgments.

Paul Campos: Yeah, absolutely. It's a way of using ideology to turn an aesthetic and cosmetic preference into a medical matter and then to moralize that medical matter. So we are medicalizing and moralizing essentially matters of fashion.

The claim that weight is an important medical issue is not completely false, it's just largely false. At the statistical extremes of thinness and fatness, there's no question that weight has some relevance. But for the vast majority of people in this culture, and including the vast majority of people who are classified as weighing too much -- especially this completely phony overweight category -- it doesn't.

Nick Schulz: One thing that has been brought up by some researchers as a significant component in a person's weight is the genetic component -- that there's a strong biological mechanism at work regulating weight. How significant do you think that is, as we look at weight and individual health and public health?

Paul Campos: It's of immense significance. And in fact, even from those sort of fat-phobic obesity researchers, pretty much all admit -- certainly, when pressed -- that the genetic component is of immense significance. The number that tends to be thrown around by obesity researchers is that something like 50-80 percent of the variation in weight between individuals is accountable solely on the basis of genetic factors -- without even taking into account things like environmental factors which of course, also might be completely beyond the control of the particular individual.

One of the things that I have been struck by, in studying this literature, is the weirdness of the assumption that the variation in body mass between individuals is a product of something other than their genetic predisposition to have a certain kind of body mass. Think of how bizarre that assumption would be in the context of something like say, height. The assumption that, say, Shaquille O'Neal on the one hand and Winona Ryder on the other, have different height because of lifestyle choices would be something that would just obviously be absurd. And yet, to a very significant extent, weight is just like height in that regard.

Nick Schulz: I see that part, although to be fair, it seems to be that one limitation of the comparison of height and weight is that if you were to overfeed people for several weeks, while their weight may vary, no one's height changes at all.

Paul Campos: Height of course, is a much slower and less variable process than weight. And so it's not by any means, it's not an exact analogy. But the evidence is overwhelming that given a certain genetic and environmental framework, the vast majority of people's weight is going to stay within a fairly narrow range over an extended period of time.

Now that's not true for everybody. There's a small percentage of people who, for example, can successfully undertake a significant long-term weight loss probably in the neighborhood of around five percent -- if they have to do that. But the vast majority of people are going to stay within a particular weight range because their bodies are genetically adapted to maintain that particular weight range and it's extremely difficult to fight against biology in that regard.

Nick Schulz: I just want to shift gears for a moment. You may have seen recently that former President Clinton has now lent his celebrity to the efforts to combat childhood obesity. In your estimation, as somebody who has studied the academic research on this, how concerned should people be about childhood overweight and obesity and what if anything should be done about it?

Paul Campos: Note, first of all, that the definition of overweight and obesity in children is produced in the following fashion. The heaviest five percent of children in terms of body mass of their particular age cohort are labeled obese. The heaviest 15 percent -- from the 80th to the 95th percentile -- of children for their particular age cohort are labeled overweight.

Now, one question which I think would naturally arise given these definition is, since it seems statistically impossible to ever avoid having a heaviest 15 percent or heaviest 5 percent of children, it's not exactly clear, what is the meaningfulness of just labeling the heaviest 15 percent of children as overweight. Obviously there's always going to be a heaviest 15 percent of children. These are the definitions that people are working with. So when you read in the media that 15 percent of American children are overweight, that's because --

Nick Schulz: -- they are defined that way.

Paul Campos: It is kind of funny -- but it's funny in a kind of morbid way -- because it's so utterly bizarre and unscientific.

As a scientific matter, the question you would want to know is are American children in fact, heavier than they were generation ago? And the answer is, yeah, they appear to be somewhat heavier.

But the notion that there's some kind of epidemic in childhood obesity is really unsupported by careful examination of the data.

When somebody says there's an epidemic of Type-2 diabetes among children, the appropriate follow up question would be, well how much is there? Try to find a figure for what the rate of Type-2 diabetes among children actually is. It is very, very difficult to do and the answer, as far as I can tell, it appears to be about one in every 10,000 children have Type-2 diabetes.

Now Type-2 diabetes is, of course, a serious illness, and I don't want to understate the significance of a child having Type-2 diabetes, because that's obviously something which is quite serious and something that we have to take very seriously and not brush off.

But the one in 10,000 hardly would equate in most people's notion of what an epidemic consists of. Listening to the obesity alarmists talk about this, you would think that one out of every 20 kids have Type-2 diabetes, or at least one out of every 100. Not one out of every 10,000.

Secondly, another claim that is made in this context is, we never used to have Type-2 diabetes in children. That this is just completely unprecedented; now this is happening because of this crisis of obesity among children. Well, then, another follow up question would be, what was the rate of Type-2 diabetes among children, say in 1975? And the answer to that question is no one has any idea because nobody keeps stats on it.

Now one explanation for that would be, well, there wasn't any Type-2 diabetes among children. Another explanation for that might be that since we didn't have nearly as much of a hysterical moral panic about this issue in 1975, nobody thought it was worth keeping statistics on extremely rare conditions.

So we don't even know for a fact that the rate of Type-2 diabetes among children is actually increased at all. This is all completely anecdotal.

Nick Schulz: What are some of the more egregious excesses in the war on fat?

Paul Campos: One that really sums up the depth of the craziness on this is the initiative that has been undertaken in Arkansas by Gov. Huckabee, who is pushing through legislation to mandate the placement of a weight index that is on the report cards of all children in Arkansas Public Schools to grade them by weight. A similar initiative has just been passed in Texas and others along the same line are being considered in a variety of other states.

I cannot emphasize enough on what a terrible, terrible idea that strikes me to be. We are taking children and weighing them in school for the purposes of reporting their BMI, as if their weight is supposed to be a major accomplishment which they're supposed to be pursuing in the context of their education. This is just so destructive. Children don't even told that they're fat. The parents of those children don't need to be told that their children are fat. The notion that we somehow have to be focusing a program on people who are on the right side of a bell curve and distribution in terms of body mass in order to somehow magically produce a result that we've never been able to produce before, as invidious as that idea is when it's applied to adults, when applied to children, it's just criminal as far I'm concerned.

Nick Schulz: Paul thank you so much for talking to us.

Paul Campos: Thank you.



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