Andrew Sullivan rounds some of this up for us. Atlantic bloggers are all talking about fat. No, this isn’t some delayed MJ punditry going on here.
Megan McArdle interviews Paul Campos:
Megan: Let’s start with the first. If there’s one thing that everyone in America knows, it’s that being fat is really unhealthy. Why do you call it a fake problem?
Paul: The correlations between higher weight and greater health risk are weak except at statistical extremes. The extent to which those correlations are causal is poorly established. There is literally not a shred of evidence that turning fat people into thin people improves their health. And the reason there’s no evidence is that there’s no way to do it.
So saying “let’s improve health by turning fat people into thin people” is every bit as irrational as saying “let’s improve health by turning men into women or old people into young people”. Actually it’s a lot crazier, because there actually are significant health differences between men and women and the old and the young — much more so than between the fat and the thin.
Campos links to the interview at LGM:
An interesting ideological aspect of this is the degree to which lefty folks who usually have no trouble understanding structural arguments turn into the offspring of Horatio Alger and Ayn Rand when it comes to fat. For instance, if you said to such people “We know how to end poverty. Just tell poor people to do X and Y, and as long as they do X and Y they won’t be poor,” and then it turned out that a social policy based on telling poor people to do X and Y resulted in failure 98% of the time, and in fact produced a net increase in the poverty rate, they would consider your opinion to be idiotic on its face.
As someone who feels totally fine slapping additional taxes on soda or cigarettes — in part to reduce public health consequences like obesity and lung cancer — let me say that I don’t think the best justification for this policy has a whole lot to do with to do with reducing health spending. A less obese population that doesn’t die young from fast-onset lung cancer might end up spending more on health care. Totally possible.
(1) Both Paul Campos and Megan McArdle appear to have missed the point by several quadrants. We have managed to turn thin people into fat people–a great many Americans today who are fat would be thin if they had lived forty years earlier in the America-that-was a generation ago. Surely if we can do this, we can undo it?
(2) Both Paul Campos and Megan McArdle appear to have missed the point by several quadrants. Changing sedentary, high-cholesterol, high blood pressure, high blood sugar fat people into more active, low-cholesteral, normal blood pressure, normal blood sugar fat people certainly does improve their health.
Democracy in America at The Economist:
Part of Mr Campos’s opposition to controlling obesity stems from a quibble over the definition of “obese”. The definition applied by the medical profession since the 1980s has been a body-mass index (BMI, or weight over height squared—kg/m) of 30 or greater. At 203 lbs for a 5’9″ man, that definition seems reasonable, but Mr Campos says serious health effects don’t set in until BMI hits 35. His claim seems to be belied by the study in Health Affairs to which he was responding, which found that annual health costs for the obese, ie those with a BMI above 30, were 42% higher per capita than those for someone of normal weight. Even if most of that higher spending and reduced health were clustered at BMI 35 and above, the relevance seems unclear: the incidence of the 35-and-up BMI group has risen dramatically over the past 30 years as well.
A related argument seems to be based on poor mathematical thinking. The huge rise in “obesity”, Mr Campos says, merely reflects the fact that millions of people have risen from BMIs in the high 20s to BMIs in the low 30s; and those two groups show no measurable difference in health. But this would be true no matter where one set the obesity marker. If it were set at 35, a huge rise in obesity would mean millions had shifted from 34 to 36, and there might be little health difference between those two groups, taken in isolation. But in fact, the huge shift from high-20s BMIs to low-30s BMIs is one part of a massive shift towards higher BMIs all across the spectrum, with all the expected health consequences; and looking at the rise in obesity is a fair way of summing that shift up.
The real problem with Mr Campos’s stance is in the way he phrases the issue: the impossibility of “turning fat people into thin people.” He is right that it’s almost impossible for an obese person to get to normal weight and stay there. But most of the public-health attention isn’t focused on getting people who are already obese to lose weight. It’s focused on making sure that people who are normal or overweight get no fatter. It’s true that who is fattest among us is determined by environmental and genetic factors over which we have little control, and it is thus very hard for people who are fat to lose weight. But this is irrelevant to the issue of the massive population-wide shift that has pushed the BMIs of all Americans up. The statistics on that shift are stunning, as this PowerPoint display from the Centers for Disease Control shows. In 1985, not a single American state had a prevalence of obesity over 14%. In 2008, not a single American state had a prevalence under 15%; six states had prevalences over 30%. If the problem is less evident to Mr Campos, it may be because he lives in Colorado, the only state in the country where obesity prevalence remains under 20%.
Nonetheless, a dose of Campos in one’s anti-obesity cocktail keeps one humble about assuming too much. The academic world tends to lump together the slightly overweight, the unhealthy people who have large body sizes, the pre-obese, the active obese and the sedentary obese all into one category. Doing this inevitably leads to public interest group fear-mongering and implies that the problem is unipolar and thus solvable by their preferred approach. Campos — and McArdle — are right to approach the obesity issue with a skeptical, critical eye. But even Campos — and you can see this in his interview with McArdle and in his book, The Obesity Myth — does not make the claim that food consumption and lifestyle aren’t public health problems.McArdle approaches obesity as if it were a Foucauldian construct: a category invented by the government to justify an exercise of power. The government has no business intervening on the level of individual choice and it shouldn’t get into the business of behavioral suasion because it always fails. She’s right to note that information about health risks associated with overconsuming fat and sugar and salt are saturated throughout society, even supersaturated. Everyone knows how bad this stuff can be. For her, that’s the end of the argument. Government can help to provide information about how to make better choices, but it cannot and should not try to persuade people to make better choices. Indeed, the push for people to make better choices produces the stigma that makes the bad thing bad in the first place.This assumes that the stigma itself is misplaced. It isn’t. Fat stigma is bad and harmful, and it ought to be reduced. But reducing fat stigma doesn’t reduce the incidence of obesity; it actually seems to increase it in certain populations. What produces fat stigma is not a government or culture that hectors people to lose weight and exercise and then excoriates them when they can’t; it’s a government that expects individuals to lose weight on their own (which is next to impossible) while making policy that keeps people fat. The discrepancy between expectations and reality is cruel, especially for children.
McArdle responds to Ambinder’s first post:
I don’t really care if the government tries to persuade people to make better choices. But in general, government efforts to persuade people have failed. Government efforts at transparency are useful–it was the surgeon general’s report on smoking and cancer that started the downward trend in cigarette consumption (and, natch, some of the upward trend in our waistlines). Government coercion has also proven somewhat effective–cigarette taxation and anti-smoking laws have, as far as I can tell, helped cut into smoking quite a bit.
[…] I’m not disputing that the environment has changed in ways that seem to make people get fatter–indeed, you’d have to be a total moron to dispute this. Nor am I disputing that some of this can be laid at the door of government, like our ridiculous agriculture subsidies, and even our zoning laws. On the other hand, it’s also true that people really liked riding around in cars even before zoning–unless the landscape makes car ownership prohibitively expensive, people tend to embrace it, which is why car ownership is increasing so fast even in places like Europe. Either way, this cannot be the only reason. US government policy and bad zoning is not making people fat in Britain or Australia.
More McArdle (posted before Ambinder):
To put it another way: I have NEVER had a BMI above the normal range. How much more awesome am I than you? 30%? After all, you have to work at it. My willpower is apparently 100% natural.
I fearlessly predict that more than one person will respond with some variation on “there were no fat people in concentration camps/but I told you, I totally lost 20 pounds last year by taking up marathon running!” Yes, we could solve America’s obesity problem by putting everyone in the country on sawdust bread and cabbage soup. We could also just shoot anyone whose BMI is over 28. Are these good solutions? Because short of that, we don’t have much.
Ambinder responds to McArdle’s second post:
If everyone responded to the pressures of (a) a corn diet (b) TV advertising (c) the ubiquity of fat and sugary foods (d) the information disseminated by the government and the diet industry (e) technological enabling of a sedentary lifestyle in the same way, it is relatively easy to answer the question. If you tend to blame individuals for their choices, then your answer will be no. But the crucial fact is that obesity does not treat everyone equally. It discriminates according to status, class and geography. And its negative externalities are absorbed by these vulnerable populations. And in children, being overweight is increasingly become the default. Unless someone intervenes, if you go with the flow, if you live in a vulnerable population, you’re going to be quite vulnerable to an obesogenic lifestyle. This debate isn’t about government dictating lifestyle choices to adults. It’s about whether changing policy can reduce obesity among children.
James Fallows weighs in:
Our basic nature as human beings can’t have changed in that time. Nor can our genetics. If you’ve lived in Asia, you know that Japanese and Chinese people are on average taller and much heavier than they were a generation ago. I have met old women in China who looked barely four feet tall. In Beijing or Tokyo 25 years ago, I was always the tallest person on the subway or in a crowd; now, I usually see a few young men over 6’2″. But in these countries there’s an obvious explanation: poor nutrition artificially limited people’s growth before, and the limit is being removed.
Exactly what this means in policies is beyond my time or ambition here. Basically I agree with Marc Ambinder’s statement below. I chime in on the issue mainly to express this view: denying that America’s obesity situation has changed; or that it has harmful consequences; or that it could, like smoking, be affected by public policies strikes me as antifactual denialism.
So it seems that James Fallows and Marc Ambinder and I all agree that the increase in obesity in the American population is environmental, though they seem to think I disagree, despite my having made this point several times, and have thus spent a fair amount of time disproving a point no one has made. The very point of the height example offered in my first post was to note how environment interacts with genes.
It still remains to figure what the environmental change in America is that has caused this: whether the government is largely responsible, and regardless of that, whether the government can stop it.
As I’ve said elsewhere, I don’t think the government is all that plausible as the primary source of the problem. Obesity is rising everywhere, even in poor countries. It seems to be rising fastest in the anglosphere, but then, most countries outside the anglosphere rely on self-reporting data, which produces lower estimates. Eyeballing it, people in other countries are a lot thinner. But there are also a lot more fat people in Europe than there used to be.
But leaving culpability aside, what can the government reasonably do to make us healthier? We could change our road building and build denser. But of course, as I pointed out elsewhere, while being rural is correlated with being fatter, it’s also correlated with being healthier (though that advantage may be eroding). It’s impossible to tease out the countervailing effects, so which should we do? Build up dense areas in which people will be thinner, but maybe sicker from the stress hormones of living in a noisier, more crowded area? This might be liking taking up smoking to lose weight.
I actually do talk to public health experts. Frequently. I know, for instance, that the Rudd Center for Food Policy and Obesity, which is based out of Yale, has policy briefs arguing that weight discrimination is real, it is pervasive, and it is properly understood as a social justice issue. Does Megan? If she does, she’s not mentioning it. But it seems like the sort of thing you’d want to address if your argument is that obesity researchers are simply revolted by fat people and want them to face more social stigma.
Indeed, none of my many talks with obesity researchers have touched on the issue of the poor being idiots. Nor do they seem to think that the obese are insufficiently aware of society’s aesthetic standards. Megan doesn’t have straw men here. She has invented imaginary friends for her argument.
Rather, the obesity researchers I know believe a number of complicated and dispiriting things. One is that the human brain is wired to protect against the dangers of caloric scarcity. As a species, we have evolved to maximize caloric intake, to make the most of periods of abundance.
The problem is, we now live amid constant abundance. Food is not only available, but cheap. It is the center of our social lives and the respite from our workdays. It is the way we spend time with our families and the way we connect with our culture. It is how we meet mates and hang out with friends. Corporations spends hundreds of billions of dollars developing ways to make food taste better and creating advertising campaigns to make us want it more. Restaurants and drive-throughs and frozen foods have reduced the energy required to create a meal. Portion sizes have shot up. And even as our caloric inputs have grown, our expenditures have decreased. We drive rather than walk. We sit rather than stand. We work at desks rather than in fields. This is why obesity experts think Americans are fatter. Megan may, again, be aware of this research. If so, she’s not letting us know about it.
One can do this over and over again. I think there’s decent Campos-style evidence that policy initiatives that amount to government hectoring of people about their wastelines is going to be at best useless. But there’s much more to the policy world. The government provides lunch to tons of children, and determines what stuff is in their school’s vending machines and apples are better for you than Fritos; baked potatoes are better for you than french fries.
The Opinionator at NYT picks up the conversation.
Pascal-Emmanuel Gobry at The American Scene reads McArdle and takes the conversation somewhere else (cigarette taxes). The post ends:
One of the reasons I don’t think of myself as a libertarian even though they’re the group whose actual policy preferences most closely mirror mine is because of things like this. Legislation reflects a society’s moral values. In fact, it should reflect a society’s moral values, consistent with individual freedoms, because it is what a democratic polis is all about: a nation deciding by which rules it wants to live.
Government can’t and won’t “just get out of our lives”, simply because what you describe as “getting out of our lives” isn’t the same thing as what I describe as “getting out of our lives”, and, until Jim Manzi finally succeeds at creating evidence-based social science, there is no scientific way to decide what government should or should not do — and nor should there be.
So if you want to disincentivize smoking through sin taxes, that’s perfectly fine. It’s okay to have public policy that disincentivizes bad things just because they’re bad, without having to make budget projections over the next 30 years. I’m willing to pay extra to feed my addiction. But don’t lie about the real reason you’re doing it.
And remember, next time you see me light up — I’m doing my part to save healthcare and pensions.
Joe Carter at First Things:
While I agree with Gobry that disincentivizing smoking through sin taxes is legitimate and that we should be honest about our reasons, I think it can be taken too far. Taxation shouldn’t be used as means of instituting a Healthocracy in which the government uses the tax code to enforce a particular view of health-based morality. From a purely moral point of view, sin taxes are an illegitimate means of controlling the behavior of the citizenry. We should not rely on the state to use its tax code to intervene in an area that is the responsibility of society’s mediating institutions.
From a purely economic standpoint, though, sin taxes make more sense. This form of taxation can be an effective means of reimbursing the state for the cost incurred by participating in a particular negative behavior that it wishes to disincentivize (there is a moral component to disincentivization, of course, but that is true of all legislation).
UPDATE: McArdle responds to Klein and others
UPDATE #2: McArlde’s second post on the subject
Alex Tabarrok on McArdle
Ezra Klein responds
And more Klein, linking to Mark Ames, who goes very personal. Klein:
The contracts McArdle pere won as managing director for the General Contractor’s Association have no bearing on Megan McArdle’s argument that health-care reform will reduce private-sector profits and suppress drug innovation over the long term. Megan is either wrong about that or she’s right about it. As I’ve argued at length, I think she’s wrong. But I don’t need to drag her family into that argument. And nor should I.
UPDATE #3: McArdle and David Frum argue at Bloggingheads