Discover more from Burnt Toast by Virginia Sole-Smith
Skinny People Die Too.
But we can't sell them weight loss drugs.
Content warning: Frequent use of “O-words.” As I’ve noted before, I use “ob*sity” when it’s necessary to reference that word in my own voice, but it’s not my usual practice to edit the word out of other people’s quotes, or when discussing scientific literature that hinges on these terms.
Back in 2013, I wrote a story for Marie Claire called Can You Be Heavy And Healthy?
It’s not a long piece. It’s not my best work. In rereading it, there are things I would change (like, why did we give the exact weight of the woman whose story led the piece). But it was a kind of turning-point for me. It was the first time I succeeded in persuading a mainstream media outlet to let me write about Health At Every Size. It was the first time I interviewed the brilliant Lindo Bacon, who was unbelievably patient and generous with their knowledge. It was the story that enabled me to start connecting some key dots, to see all the ways that weight does not equal health.
While reporting that story, I interviewed an epidemiologist named Katherine Flegal, PhD, who was then a senior scientist at the National Center for Health Statistics at the Centers for Disease Control and Prevention. In 2005, Dr. Flegal published a paper in JAMA called “Excess Deaths Associated with Underweight, Overweight and Obesity,” which analyzed the number of deaths associated with each Body Mass Index group in the year 2000. Flegal and her colleagues concluded that overweight BMIs were associated with “slightly but significantly fewer deaths” than normal weight BMIs. Both obese and underweight BMIs were associated with excess deaths compared to the normal weight group, but Dr. Flegal’s analysis linked obesity with less than 5 percent of deaths while a paper that came out the year prior had linked BMIs in the obese range to over 15 percent of deaths. “There was a lot of criticism that our finding was very surprising,” Dr. Flegal told me in 2013. “But it really wasn’t, because many other studies had supported our findings.” So many, in fact, that in 2013, Dr. Flegal and her colleagues published a systematic literature review of 97 studies, involving almost 3 million participants, and concluded, again, that having an overweight BMI is associated with a lower rate of death than a normal BMI in 80 percent of studies. They also found no association with mortality at the low end of the obese range.
A literature review is not about producing new science. It’s about assessing the science previously done, to see what we already know. And what we already knew, both in 2005 and 2013, was that the Body Mass Index categories were arbitrarily drawn, terrible measures of health. I wrote more about the history of BMI here, but one crucial event always worth revisiting was in 1998, when the National Institutes of Health’s Obesity Task Force lowered the BMI’s cut-off points for each weight category, a math equation that moved 29 million Americans who had previously been classified as normal weight or just overweight into the overweight and obese categories. Many researchers and advocates criticized the decision for pathologizing larger bodies because of the research (some of which Dr. Flegal would later analyze, some of which I wrote about here) showing the difficulties of drawing straight lines between weight and health. And there’s no question it benefited the diet industry by creating a larger market for the flurry of weight loss drugs that the FDA approved right around the same time: Dexfenfluramine (sold as Redux) in 1996, sibutramine (sold as Meridia) in 1997, and orlistat (sold as Xenical and Alli) in 1999.
But as the writer and public health doctoral student Marquisele Mercedes wrote so eloquently in this brilliant investigation of our newest FDA-approved weight loss drug Wegovy, we are prone to selective memory when it comes to weight and health. By the time I interviewed Dr. Flegal, in 2013, the controversy of the NIH decision was ancient history and her exploration of (all of the preexisting data on) the weak link between weight and mortality felt blisteringly provocative, especially to the obesity research community. “I think people will be endlessly surprised by these findings,” she told me then. “Harvard School of Public Health is very perturbed. They’re having a big symposium today to talk about what’s wrong with this.”
I remember being surprised that Dr. Flegal shared that with a journalist, but I also wasn’t in a position at that time to do much with the information. That quote didn’t even make it into the final piece; I just pulled it out of the 8-year-old interview transcript (thank you Dropbox for saving everything). And Dr. Flegal offered no theories as to why HSPH was challenging her work; she was completely professional to the point of being rather hard to quote (especially in a women’s magazine where I had previously written articles with headlines like “She dumped him during sex!” Scientific American we were not).
Well. Dr. Flegal is now retired from the CDC, and last week, she told her story. Her article, titled, “The Obesity Wars and the Education of a Researcher: A Personal Account” appeared in the journal Progress in Cardiovascular Diseases. In it, she details the backlash to both her 2005 and 2013 papers, calling out the flawed methodology her critics used to discredit her work and also detailing the “aggressive campaign that included insults, errors, misinformation, social media posts, behind-the-scenes gossip and maneuvers” that obesity researchers launched against her. It’s a staggering read. Several well-known scholars gave talks and published papers trying to discredit Dr. Flegal and her work even though their own work had contained (“buried” is another word we could use) many of the same findings. They talk frequently about their fear that her research would “confuse” and “mislead” the general public… with facts?
Fatphobia and misogyny are woven throughout the story, of course. Dr. Flegal writes:
Some attacks were surprisingly petty. At one point, Professor 1 posted in a discussion group regarding salt intake that JAMA had shown a track record of poor editorial judgment by publishing “Kathy Flegal's terrible analyses” on overweight and mortality. Similarly, again using a diminutive form of my name, Professor 1 told one reporter: “Kathy Flegal just doesn't get it”.41
Ah yes. Pretending familiarity while asserting your own superiority by giving a woman a nickname (whether she uses it or not). I believe that’s page 16 of the mansplaining handbook. And if you’ve been reading my work for any time at all and still don’t believe that weight stigma informs how obesity research gets done, I’ll refer you to the Twitter response to Dr. Flegal’s piece:
There are other valid criticisms to be made of Dr. Flegal’s work. Namely that she is not, actually, all that radical. She’s a (formerly government-employed) epidemiologist who studies obesity: “She’s still invested in hierarchical notions of weight and health, and she’s a highly cited, highly influential person in the scientists, as well as white,” says Marquisele, who wrote the Wegovy piece, and is completing her PhD at Brown University School of Public Health, where she specializes in weight stigma, racism and critical public health studies. Flegal’s published body of work never questions the utility of BMI, nor does she ever note the way weight categories reinforce and perpetuate anti-fat bias. All she did was point out that some portion of folks in bigger bodies will not die sooner than thin people because of their bodies.
And yet: “Flegal experienced bullying, harassment and slander for stepping just a smidge away from the hard line of her field,” says Marquisele (who also goes by Mikey). “Imagine what that means for the rest of us who are outright challenging fat-demonizing paradigms, who live in marginalized bodies, and who are not well-established researchers with influential institutional affiliations.”
It means we have a hell of a lot of work to do.
For more of this conversation: Marquisele Mercedes, aka Mikey, aka @marquisele and @fatmarquisele, is joining me on this Thursday’s audio newsletter! We discuss anti-fat bias and industry influence in weight research, the infiltration of diet culture in public health discourse, and so much more. Make sure to subscribe so you don’t miss it. Check out more of Mikey’s scholarship and writing here, and support her Patreon here.
Behind the scenes:
To everyone still waiting so patiently for their book: Yes I signed them all (and Violet signed a few!) no I haven’t gotten to the post office yet. This week! It’s gonna happen! (If you also want a personalized signed copy, consider becoming a Founding Member.)