2. Is America's Obesity Epidemic For Real?

Americans keep putting on pounds. So is it time for a cheeseburger tax? Or would a chill pill be the best medicine? In this episode, we explore the underbelly of fat through the eyes of a 280-pound woman, a top White House doctor, and a couple of overweight academics.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:01Stephen J. Dubner?

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• 0:43Stephen J. Dubner?

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• 1:26Stephen J. Dubner?

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• 1:54Stephen J. Dubner?

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• 2:30Stephen J. Dubner?

  There are a lot of reasons to come to New York City, like going out to eat. But not everyone eats five meals, back to back, all in one evening. We're starting at Big Nick's on the Upper West Side. It's famous for a sumo burger, one full pound of ground beef.

• 2:49Speaker 01

  Yeah, you know, if you're in any place, the best thing to do is to eat everything you can, I think, especially when you're traveling. You just have to eat everything that you can't get at home, you know?

• 3:01Stephen J. Dubner?

  So it's a little after four in the afternoon on a Saturday. So this is your Saturday afternoon, evening excursion?

• 3:08Speaker 02

  Big Nick's for pizza and apparently a burger. Zabar's for goodies. French roast for wine and mussels. And then we're going to Grace's Pupaya for a hot dog and Magnolia for cupcakes.

• 3:28Stephen J. Dubner?

  Awesome.

• 3:29Speaker 02

  But we're walking.

• 3:30Speaker 01

  We're walking.

• 3:31Speaker 02

  We're walking to all of them.

• 3:32Speaker 01

  We're walking.

• 3:34Stephen J. Dubner?

  Have you thought about total calorie count at the end of the day?

• 3:37Speaker 01

  No way.

• 3:46Speaker 03

  This is Freakonomics Radio, a new podcast about the hidden side of everything. In this episode, the underbelly of fat through the eyes of a 280-pound woman, a top White House health care adviser, and a couple of overweight academics. Here's your host, Stephen Dubner.

• 4:03Stephen J. Dubner?

  I was in Chicago last week and caught up with my friend and Freakonomics co-author Steve Levitt. He took me to eat at a restaurant he loves. Charlie Trotter's? Uh-uh. So Levitt, where are we here?

• 4:16Speaker 04

  Kentucky Fried Chicken, one of my favorite restaurants.

• 4:19Stephen J. Dubner?

  And which Kentucky Fried Chicken are we in?

• 4:21Speaker 04

  Garfield Boulevard. Kind of in the-- it's kind of a rough neighborhood, near the New York City of Chicago.

• 4:27Stephen J. Dubner?

  South side of Chicago.

• 4:28Speaker 04

  Yeah. Bad enough that they have plexiglass between you and the server, if that's any indication. I don't think there have been a lot of podcasts done of this particular Kentucky Fried Chicken.

• 4:42Stephen J. Dubner?

  So Levitt, what do you think of fat people?

• 4:46Speaker 04

  Nothing. I'm not one of those people who really hates fat people. I know there are people who hate fat people, but I don't really mind fat people. I mean, people say that they're so against obesity, it's driven by some moral thing, I think, rather than some economic thing.

• 5:02Stephen J. Dubner?

  Where do you think that comes from?

• 5:05Speaker 04

  You know me, I've got nothing to say about morality.

• 5:10Stephen J. Dubner?

  Fat people. In America, they're everywhere. The federal government says that two of every three adults are overweight, and 1/3 of our children are officially obese. Over the past half-century, we've come to consume about 30% more calories each. Why? Well, fattening foods are cheap, abundant, and, let's face it, delicious. Now, as problems go, this is a strange one. Throughout history, people have struggled to get enough to eat. In many countries, they still do, and charities like the Gates Foundation are spending hundreds of millions of dollars trying to help poor children eat more.

• 5:50Stephen J. Dubner?

  Last week, Michelle Obama announced a $10 billion program to help American children eat less fat.

• 5:58Speaker 05

  So as we've seen, the surge in obesity in this country is nothing short of a public health crisis. And it's threatening our children. It's threatening our families and, more importantly, it's threatening the future of this nation.

• 6:13Stephen J. Dubner?

  Gosh, no wonder everybody hates fat people. They're bankrupting our nation. They're even threatening our national security.

• 6:21Speaker 05

  Our military leaders report that obesity is now one of the most common disqualifiers for military service. Economic experts tell us that we are spending outrageous amounts of money treating obesity-related conditions like diabetes, heart disease, and cancer.

• 6:40Stephen J. Dubner?

  Here's Ezekiel Emanuel, a doctor and bioethicist who's an advisor to the Obama administration on health care reform. He's also the older brother of Rahm Emanuel, the White House Chief of Staff.

• 6:51Speaker 06

  I mean, we're all focused on health care and diabetes and heart disease, but there's all sorts of things like the simple fact that, you know, heavier people, transportation is more, so there's more spent on gasoline, more on jet fuel. People have had to change, you know, the size of doorways, the size of chairs on airplanes and at sports stadiums. So there's a lot of hidden costs as well to the increasing girth of Americans.

• 7:18Speaker 07

  We're being blamed for everything, all the way up to global warming.

• 7:22Stephen J. Dubner?

  This is Peggy Howell. She's 5'9", 280 pounds. She wears a size 22 dress.

• 7:28Speaker 07

  I was working for a school that was associated with a religious organization in Northern California. And I worked, I had gone through the school program and graduated and then was working for them. I was working as a student counselor, a librarian, and doing accounts receivable. It was a small school, so we all wore many hats. And at one point, my boss came to me and told me that I had to lose weight or else. And I said, "Or else what?" And he said, "Or else lose your job." And I said, but I'm sorry, but I don't understand what my weight has to do with my ability to do my job.

• 8:12Speaker 07

  And he said that the fact that my weight was too high was an indication that my life was out of control and that as such, that I was not fit to counsel other students.

• 8:27Stephen J. Dubner?

  So are a lot of people anti-fat because we see obesity as a moral failing? After all, we're talking about a self-inflicted condition here, right? But is there something else going on?

• 8:39Speaker 08

  My name is Eric Oliver. I'm 43 years old. I'm a professor of political science at the University of Chicago.

• 8:45Stephen J. Dubner?

  And how tall are you and what do you weigh?

• 8:48Speaker 08

  I'm six feet tall and 190 pounds.

• 8:51Stephen J. Dubner?

  What's your BMI?

• 8:52Speaker 08

  That puts me at a BMI of 25, which is technically overweight.

• 8:57Stephen J. Dubner?

  I have to say, Eric Oliver doesn't look at all overweight. In fact, he's on the rangy side. When he discovered that his BMI, or Body Mass Index, made him technically overweight, he began to wonder about the intersection of politics and science when it comes to obesity.

• 9:14Speaker 08

  When we start designating people as overweight or obese, we are immediately putting labels on them. We are defining them relative to some standard of deviance, and that in itself is a political act. By differentiating people according to their physicality, we immediately start creating political problems. But I think more importantly, obesity is one of these issues that the science of obesity is very, very complicated. Linking anything to chronic health and predicting any kind of chronic health outcome is an incredibly difficult thing to do from a statistical standpoint. The interesting thing is, most people don't appreciate that fact. And when they start hearing information about obesity, they really do so, I think,

• 9:57Speaker 08

  based on prior conceptions and prejudices. And I think a lot of our understanding of obesity as a health issue is informed much more by our social prejudices against fat people, or by the particular financial incentives of the weight loss industry, or certain public health officials, or the bureaucratic politics of organizations like the Centers for Disease Control. And these factors are really defining how obesity is being framed as a public health issue, more than the scientific evidence itself.

• 10:29Stephen J. Dubner?

  Oliver has written a book called Fat Politics: The Real Story Behind America's Obesity Epidemic.

• 10:35Speaker 08

  The first thing I wanted to do was establish that, in fact, obesity was the health catastrophe that I assumed it to be and that everybody else was claiming it. And the more research I read into this, the more I started diving into the medical journals, the more I came to realize that the, actually, the scientific evidence linking body weight to all these health pathologies was far from clear-cut, that, in fact, the case wasn't very strong at all. And the more research I started digging into then why that was the case, the more I started hearing about findings that were hushed, politics going on within various bureaucracies to promote certain kinds of findings and suppress other kinds of findings, large debates within the

• 11:18Speaker 08

  scientific community that were not public about the nature of obesity and its relationship to health. And I came to quickly realize that there was a much more interesting political dimension to this than actually a scientific dimension.

• 11:31Stephen J. Dubner?

  Wait a minute. The scientific evidence for the dangers of weight isn't very strong? That sounds crazy. The Obama administration argues exactly the opposite. So does my doctor. His name is Conrad Bloom, and I should also say he's a professor of clinical medicine at Columbia University's College of Physicians and Surgeons.

• 11:52Speaker 09

  Overweight and the insulin resistance that go along with it would be the underlying problem causing what we call metabolic syndrome, which is a constellation of heart risk factors, including high blood glucose levels and development of diabetes, as well as high triglyceride levels, high blood pressure, and low levels of HDL cholesterol, that is, the good part of the blood cholesterol.

• 12:22Stephen J. Dubner?

  And what is your level of confidence when you say that overweight drives these diseases as opposed to being correlated? In other words, what's your level of confidence that this is causal, not just correlated?

• 12:35Speaker 09

  My level of confidence is virtually 100%. I have seen a large number of instances where we are able to cure all of these complications of overweight and obesity by having people lose weight. So if we treat the underlying disease, which is overweight, we can, in nearly all cases, see the diseases disappear.

• 13:05Stephen J. Dubner?

  Holy cow. Who am I supposed to believe? The Obama administration and my own doctor? A smart, caring professional whose decades of experience tell him that losing weight makes diseases disappear? Or some rogue political scientist? So here's what you've written. "Obesity is neither a disease nor a cause of disease." I'm guessing that nine out of 10, or 95 out of 100 people who read that would say, "What is he talking about? Of course it's a disease, or at least a cause of disease." And yet, at the very root level, you say no. Explain.

• 13:40Speaker 08

  Right. The difficulty with obesity, as with any kind of chronic health issue, is that we really don't know the causal linkages between weighing too much and most diseases. We do know that, I mean, being very, very heavy is hard on your body. It's very hard on your joints. If you're a woman, it causes an increase in certain kinds of hormones, which can contribute to higher rates of certain kinds of cancers. So we do know there are some causal effects of weighing too much. But if we look at heart disease, if we look at most cancers, if we look at stroke, even if we look at diabetes, and this is probably the most contentious issue, the causal linkages between having a lot of body fat and these conditions are far from clear.

• 14:22Stephen J. Dubner?

  You write that in 2004, the Centers for Disease Control estimated that obesity is killing 400,000 people a year. Right? Do I have that right? That obesity is killing 400,000 people a year?

• 14:32Speaker 08

  This is what they issued. They issued a report, an article that was published in the Journal of the American Medical Association, claiming that, yes, obesity was killing 400,000 people a year.

• 14:40Stephen J. Dubner?

  And you vehemently disagree, correct?

• 14:43Speaker 08

  Well, what happened was, there were a number of problems with this report. One of which, it was based on data that were about 30 years old. Secondly, the report itself made some computational errors that called into question the actual findings there and the conclusions. Another set of researchers from a different division within CDC then later issued a report that said, in fact, it was, that number was probably only closer to like 20,000 people a year. And in fact, there was just, there were just as many people dying from weighing too little as there were from weighing too much.

• 15:19Stephen J. Dubner?

  And we're back at Big Nick's, home of the Sumo Burger.

• 15:22Speaker 01

  Okay, well, let's see. There's a lot of burgers on here. There's a chili burger, chili cheeseburger, ooh, a cocktail burger. I like the sound of it, but I don't know if I'm gonna get that one. Ooh, aloha burger, sounds fun. Um, oh, God, I don't know. I think, I think I'm just gonna have the, the Mediterranean burger because it has anchovies on it, and I love anchovies.

• 15:48Stephen J. Dubner?

  What else is on?

• 15:49Speaker 01

  Oh, it's a, it's a Grecian burger with anchovies, slice of feta cheese and tomato. Second to none, it actually says that.

• 15:57Stephen J. Dubner?

  So, we eat more than we used to, and we weigh more than we used to. Some people think this poses a terrible danger. The First Lady's Let's Move program addresses some of this, like people's access to healthy food. We couldn't get Michelle Obama to talk about her program, but Ezekiel Emanuel described it for us.

• 16:17Speaker 06

  Well, as you may know, the First Lady has launched this Let's Move campaign, which is aimed mainly at children, and has four pillars. The first pillar is to improve nutrition in schools, and to get more fruits and vegetables on the school lunches. The second pillar is more physical activity, so more physical activity at school, more changing the built environment, so there's more walkways, more bike paths, trying to encourage participation in sports leagues. The third pillar is to give people more access to foods, so eliminating food deserts and

• 16:59Speaker 06

  such, so that people in the inner city and in rural areas where they don't have access necessarily to fresh fruits and vegetables, or they don't have grocery stores that carry them, to increase their access. And the last is to really give parents information that they need to make healthy choices, so that they can have some reliable and effective information to act on.

• 17:26Stephen J. Dubner?

  Those sound like fantastic ideas. How well do you think it'll work?

• 17:30Speaker 06

  I think that I detect a bit of skepticism in your voice, and I think that any single one of them alone is probably not sufficient. Together, as well as with a change in social attitudes around obesity and around each one of those issues, eating better, physical activity, food deserts, I think they can make a big difference.

• 17:56Speaker 10

  There's a couple really critical things that are missing from the "let's move" policy. It's been tried 15 different times, it's never been effective.

• 18:05Stephen J. Dubner?

  Brian Wansink is the author of "Mindless Eating," and he's a researcher at Cornell who, for years, has been studying how we eat. He also spent some time as a top nutrition official at the US Department of Agriculture. He helped reshape the food pyramid. When Wansink looks at the war on obesity, he sees a lot of people with an incentive to hype the problem.

• 18:26Speaker 10

  There's a tremendous number of people who profit by hyping obesity. I don't think it's the epidemic that a lot of people like to paint it as, but here's who profits. There's a lot of diet doctors, there's a lot of bariaticians, there's a lot of fly-by-night, super-diet drug salespeople benefit by making this the biggest threat to the world. But there's a huge number of academics who benefit by doing this, because there is so much money in grants, whether it be the NIH grant, or CDC, or whatever, that is out there if academics can make the case that this is a huge fat world that's just going to heck. They benefit. And I'm not saying there isn't a problem, but I'm saying it gets really blown out of

• 19:10Speaker 10

  proportion, because there's a lot of people who are motivated to do so.

• 19:13Stephen J. Dubner?

  But here's the thing. Even today, without universal health care, the government pays about 45% of all health care costs. So I'm paying for your medical costs, and you're paying for mine. In fact, one economist has calculated that every time you order a cheeseburger instead of a salad, you add $2.50 in collective, long-term health care costs. Now, if these costs are being driven higher every time I eat something fattening, what are you supposed to do about it? So I asked Ezekiel Emanuel, is it time for a cheeseburger tax?

• 19:48Speaker 06

  I can't answer that question. And that's a political question. When is the right time for a cheeseburger tax? You know, I think you got the wrong Emanuel brother.

• 19:57Stephen J. Dubner?

  (laughing)

• 19:58Speaker 06

  Look, I mean, you know, a tax is one way, as you yourselves know, and in Freakonomics, the other alternative is to reduce the price of things that are, make you healthy. So we could actually reduce the price of fruits and vegetables and encourage their consumption by having them be more, less costly. So there are lots of ways of doing this, and a tax is, you know, that's just one approach and by no means the only approach. We also know that how you display items, say, in a cafeteria, a school cafeteria, where you position them, how you make them look in terms of whether they look appetizing or they look, the vegetables

• 20:43Speaker 06

  look wilted, all of that stuff makes a difference.

• 20:46Stephen J. Dubner?

  But how much difference do such well-meaning nudges actually make? I asked Brian Wansink.

• 20:52Speaker 10

  When we look at calorie labeling, for instance, the people it seems to have influenced the most are the people who already do eat pretty well. It's influenced the people who already do know roughly how many calories are in something. And I think the reason the needle's not moving is that what it did is it stirred up a bunch of dust and had a bunch of people kind of waving their arms and clapping, but it didn't influence the people who probably really need to change, because they either just don't care or it's too much effort.

• 21:23Stephen J. Dubner?

  Too much effort? Why? Because eating is fun. It's social. It's life-sustaining. It's finger-licking good. So how are we supposed to think about all this? Americans have gotten heavier, but this might not be as dangerous as we've come to think. A lot of smart people are working hard to get Americans to eat better. But given the quirks of human nature, a lot of this effort will likely be wasted. And then there's Eric Oliver, who says the reason so many people think fat is so dangerous is because obesity researchers, even those who write for top medical journals,

• 22:03Stephen J. Dubner?

  are woefully unsophisticated when it comes to statistical analysis, and that they failed to prove that fat is the cause of health problems like diabetes and heart disease. So it sounds like you're saying that calories are relatively cheap, and that's good, because we need calories and we enjoy them. And that's not bad, because weight in and of itself is not dangerous. So really, what might be the best medicine is for everybody just to relax a little bit? Exactly.

• 22:35Speaker 11

  This is a ice cream burger.

• 22:38Stephen J. Dubner?

  An ice cream burger?

• 22:40Speaker 11

  Mini burger.

• 22:43Stephen J. Dubner?

  Can you tell me what's in the ice cream burger?

• 22:44Speaker 11

  It's like a cookie, a chocolate chip cookie with ice cream in the middle. They have vanilla, chocolate, or strawberry, and...

• 22:52Stephen J. Dubner?

  Beautiful.

• 23:02Speaker 03

  This episode of Freakonomics Radio is produced by Stephen Dubner, BMI 24.8, normal, with production help from Molly Webster, 21, just perfect fightin' weight, and Jesse Baker, the winner, with a 20.4 BMI. Subscribe to this podcast on iTunes, and you'll get the next episode in your sleep. Go to Freakonomics.com to read more about the hidden side of everything. Thanks for listening.

• 23:35Stephen J. Dubner?

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• 24:08Stephen J. Dubner?

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• 24:52Stephen J. Dubner?

  So they are looking ahead and investing $80 billion in infrastructure upgrades and are committed to fueling growth in ways that benefit all customers so that reliable and affordable energy is accessible for generations to come. Go to southerncompany.com to learn more. Southern Company, building the future of energy.

• 25:16Speaker 12

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