As the redness moves from one state to others nearby, it seemed to dem-onstrate that obesity was infecting the population with a virus-like speed.
The PowerPoint slides completely changed the way many health professionals conceptualized obesity as a problem. Rather than simply being seen as a series of numbers, people viewed obesity in spatial terms, like an unfolding trend. “When we first began to use these slides in 1998,” Dietz observed,
invariably the audience responded with a growing murmur, then a gasp as the increase in the prevalence unfolded. Today these maps provide a good example of how effectively data can be dis-played to illustrate a point. After people have seen the maps, we no longer have to discuss whether a problem with obesity exists.
These maps have shifted the discussion from whether a problem exists to what we should do about the epidemic.12
Simply by virtue of the visual presentation of the data, the CDC maps could convince people that America’s weight gain was, in fact, a real
“epidemic.”
The slides were effective not simply because of their visual power, but also because Dietz made the slides publicly available on a CDC website. Soon, obesity researchers, government officials, and academ-ics across the country (myself included) were downloading the maps and using them in presentations. We were, in effect, carriers of the dis-ease model, transmitting it across a much larger population. With the maps now being widely disseminated among the scientific community, the “obesity epidemic” was quickly becoming a broadly accepted char-acterization of America’s weight growth. Articles started appearing in the major medical and scientific journals that began characterizing obe-sity as an “epidemic”—something that was new; prior to 1998 obeobe-sity rarely had been characterized this way. In 1999, the Journal of the Ameri-can Medical Association devoted a special issue to obesity that included the maps and an article that Dietz coauthored decrying the obesity “epi-demic.”13 Articles in the medical journals, in turn, shaped the coverage of obesity in major news publications, such as the New York Times and the Washington Post, which are always keen to report the trends coming out of scientific professions. These stories then got picked up by the major news networks, weekly magazines, and small town papers. The idea of an obesity epidemic spread like wildfire and was quickly
be-coming an accepted fact. And, it all started with a simple PowerPoint presentation.
The problem, however, is that the CDC maps are somewhat mis-leading. To begin with, the maps only show the percentage of people in each state with a BMI greater than 29; they do not show the spread of a disease. By using state boundaries, the maps also exaggerate the extent of obesity because the geographic size of a state doesn’t relate to the size of its population—North Dakota is pictured as the functional equivalent of Pennsylvania even though it has a fraction of the Key-stone State’s population. The colors on the maps are also overly evoca-tive, going from cool blues to hot reds as the obesity rates increase, thus giving the impression of increasing danger from an epidemic “hot zone.”
Finally, picturing the rise of obesity in this geographic way makes it seem like it is some type of spreading infection, like a virus that mi-grates from one state to another. In reality, weight gain has been most highly concentrated among certain portions of the population, particu-larly the poor and minorities. The reason the first “outbreaks” of obe-sity were in Mississippi, Alabama, and West Virginia was not because they were near some viral source but because these states are largely rural and poor.
Nevertheless, despite their misleading nature, these maps are still widely accepted and continue to be used to this day. They have been incorporated in countless scientific presentations on the obesity epi-demic and were featured in the surgeon general’s 2001 Call to Action to Prevent and Decrease Overweight and Obesity, the government’s first ma-jor proclamation about the dangers of obesity. “Nothing,” Dietz believes,
“has been more effective at increasing the visibility of the obesity epi-demic than the CDC slides.”14 And, he is right. By simply repackaging data in map form, America’s recent weight gains have become widely interpreted as a rampant epidemic, spiraling out of control.
The Diseasing of America
Of course, the CDC maps are not entirely responsible for the idea of an obesity epidemic. The characterization of our growing weight as an epidemic is emblematic of a much larger trend in American medicine—
the transformation of nonpathological physical states into diseases.
Over the past few decades, numerous physical states that, by them-selves, are not necessarily harmful, have come to be labeled as dis-eases. The condition of high blood pressure has now become the disease of “hypertension,” malaise is often diagnosed as “depression,”
unruly children are afflicted with “attention deficit disorder,” a low sexual drive has become “erectile dysfunction,” and so on. Today, it seems that any physical inconvenience, symptom, or correlate of a health problem has been elevated to the status of a disease.
To understand why this is occurring, it is useful to consider our current healthcare situation in a historical light. At the beginning of the twentieth century, health, like many basic necessities, was in short supply. Infant mortality was extremely high, infectious diseases were rampant, and the average American life expectancy was only forty-eight years. American health services were highly constrained by limit-ed knowllimit-edge and resources. But as America’s economy industrializlimit-ed and its affluence increased, its population’s health began to improve.
Americans founded hospitals, established public health agencies, pro-vided health insurance for many workers and their families, and en-dowed universities to train doctors and research diseases. These investments yielded fantastic returns. As the twentieth century pro-gressed, most infectious diseases were eradicated and regular medi-cal attention became commonplace. By the century’s end, average life expectancy in the United States had increased by nearly thirty years and infant mortality plummeted.
This success, however, also created a new set of challenges. On the supply side, the health services infrastructure that had been created to eradicate polio, tuberculosis, smallpox, typhoid, and other infectious diseases lost its purpose as these conditions disappeared. Once their initial mission had succeeded, government health agencies including the CDC, medical researchers, and private health charities such as the March of Dimes needed new problems to tackle in order to justify their existence or, in the case of private companies, maintain their profits.15 The CDC, for example, first branched into nutritional research in the 1970s, then started a center for chronic disease prevention, thus expand-ing its mission far beyond its original focus on containexpand-ing insect-born diseases. On the demand side, the increasing affluence and health of the population meant that people began seeking treatments for ever more physical conditions. As we eradicated one condition after
an-other, an expectation arose that medical treatments could do ever more to increase the quality of our lives. And in many ways they have—
from surgeries to correct our vision to lotions that “correct” baldness, Americans enjoy a wealth of medical treatment options. Yet this sup-ply and demand has also restructured our basic conception of health and medical care.
First, a host of new “diseases,” “disorders,” and other maladies has emerged. Some are genuine pathologies—as Americans started living longer, chronic illness such as cancer, heart disease, and Alz-heimer’s disease have become more prevalent. But, in many instances, the “discovery” of a new disease or disorder is prompted by the mere association with an illness: high cholesterol, being correlated with heart disease, became a health problem in its own right; hypertension, be-ing correlated with stroke, became a “killer,” and so on.16 That is not to say that such conditions may not be symptomatic of some larger ills: high levels of “bad” cholesterol may indicate high levels of blood lipids, which can clog arteries and lead to heart disease. But in the rush to treat what are often the symptoms of real diseases, we end up applying the disease label to a host of conditions that are not genu-inely pathological.
Much of this increase in the number and prevalence of diseases also comes from the various interests within the “health-industrial”
complex. Academic researchers seek to identify new physical corre-lates of disease and mortality because it helps them to get published, funded, and tenured. Their findings, in turn, prompt government health agencies to issue warnings and expand their own programs.
Drug companies and doctors then capitalize on these warnings by coming out with ever new products and treatments to keep the new
“diseases” in check and fund researchers to find even more condi-tions that need constant medication. In our massive health-service economy, “market” expansion depends upon finding ever more con-ditions that can be treated as diseases, even if they are only ancillary to a real disorder. And, because this is done in the name of our health, it is largely unimpeachable.
The second consequence of our health system’s success was that our system of medical care became highly oriented around treating symptoms rather than alleviating causes of disease. Unlike earlier in-fectious diseases, such as polio or influenza, the chronic diseases that
claim most lives today are less amenable to medical cures because they often originate from nonbiological sources such as pollution or other toxins in the environment. Without an inoculation against can-cer or antibiotics to eliminate heart disease, there is little doctors can do to prevent their patients from contracting these illnesses. What doctors can do, however, is to treat both the symptoms and the asso-ciated indicators of these conditions. They can offer radiation treat-ment and chemotherapy that kill cancer cells but don’t cure cancer, or prescribe drugs such as Lipitor that lower cholesterol but don’t cure heart disease. And the focus on treating symptoms is not limited to severe or life-threatening conditions. Some of the greatest expansions in medicine have come in the treatment of everyday maladies; thus, backaches are treated with Oxycontin, anxiety with Xanax, depres-sion with Zoloft, impotence with Viagra, and so on. Today, nearly one in two American adults is taking some type of prescription medica-tion. This cornucopia of pharmaceutical treatments is changing the very way we understand health. Living well and healthy means the absence of symptoms or painful conditions, often achieved with a constant regime of medication.
Ironically, as a result of the very success of our healthcare system, we are now spending more money on less serious conditions. As research-ers identify even more esoteric health conditions to remedy and phar-maceutical companies devise more ingenious ways to treat ordinary discomforts, health costs will continue to rise even as our overall health tends to level off. These diminishing returns are most evident in the ratio between how much we spend on health care and our average life expectancy. In the fifty years between 1930 and 1980, healthcare spend-ing in the United States as a proportion of GDP increased from 4 to 8 percent; during this same time, the average American life expectancy increased from 59.7 years to 73.7 years. In financial terms, a doubling of healthcare spending yielded us fourteen years more life. Since 1980, healthcare spending has nearly doubled again (we currently spend rough 15 percent of GDP on healthcare services) but life expectancy has only increased by three years.17 Despite spending twice as much on health services, we are getting 75 percent fewer life years in return. As we become healthier and start living longer, we will continue to spend even more money on treatments for all sorts of new “diseases,” even as our overall life expectancy ceases to improve.
The Obesity Disease Boosters
Which takes us back to the creation of an “obesity epidemic.” The idea that a certain body weight should be classified as a “disease” is not driven by any clear medical facts; rather, the pressure to label obesity a “dis-ease” comes from a range of interests, from high- to low-minded, across the healthcare spectrum. Weight-loss doctors use the disease model to promote their business—once you can label fat people as “sick,” then it is easy to convince them and their insurers they need treatment and medi-cation. Government health agencies, such as the CDC, are under con-tinual budget pressure, and they sustain their budget allocations by convincing their primary “customer” (Congress) that the nation has a real health problem. Thus, they inflate the number of deaths and the se-verity of illness that result from increased weight. Academic obesity re-searchers and scientists often exaggerate or play up the dire impact of obesity in order to secure more research funding, heighten the impor-tance of their own work, or advance their own political causes. Although these various groups do not always agree or have the same aim, they end up working in concert because they share the same strategy. In order to achieve their goals, whether it is some idea of public health or simply expanding their medical practice, they want to promote the idea that obesity is a major epidemic that threatens our very survival.
No one has been more active in this campaign than the American Obesity Association (AOA). Founded in 1995 as an advocacy organiza-tion for obesity issues, the AOA has made its primary mission to get America’s governments and health insurers to treat obesity as a “seri-ous, chronic disease.” Already, they proudly boast an impressive list of accomplishments. The AOA claims to have convinced the Internal Re-view Service to make certain obesity treatments tax deductible; they have lobbied for more obesity drugs to be covered by Medicare; and they assisted the surgeon general with his 2001 Call to Action on obesity, which helped bring the idea of obesity into the national spotlight.18 Most impressive, the AOA helped get the federal Centers for Medicare and Medicaid Services in the summer of 2004 to change their official posi-tion, which originally held that obesity did not qualify as a disease.
This was a major decision. If obesity could now be considered a dis-ease, it meant that any weight-loss procedure could potentially be con-sidered a medical “treatment” and thus be subject to reimbursement,
not simply by Medicare, but also by all the major healthcare providers who pattern their coverage after Medicare.19 If the AOA has its way, anything from gastric-bypass surgery to diet programs such as Weight Watchers would be paid for by your health insurance.
Given all these achievements, it is important to consider, however, who exactly comprises the AOA. Although the AOA’s name would sug-gest that it is an organization of obese people, it is anything but a grassroots society of ordinary folks. In fact, it has only a tiny member-ship base. It gets almost all its funding from weight-loss companies, including Weight Watchers, Jenny Craig, Hoffman-La Roche (makers of the weight-loss drug Xenical), and SlimFast, and weight-loss sur-geons.20 Many of the academic and health professionals who founded the AOA and now serve on its board—among them Dr. Richard Atkinson of the University of Wisconsin and Professor Judith Stern of the Uni-versity of California, Davis—also have been paid consultants to many of these companies and themselves have professional stakes in advanc-ing the importance of obesity as a disease. Despite all its health-related trappings, the AOA is really just a lobbying group for the weight-loss industry and obesity researchers. The campaign to get obesity classi-fied as a disease is arising from the very groups who stand to benefit from an “obesity epidemic.”
The AOA’s campaign has been joined by a wide range of participants, some with very high-minded intentions. For example, one of the biggest proponents of America’s “obesity epidemic” is Marion Nestle, a nutri-tionist from New York University and one of the leading critics of America’s food industry. In numerous articles and interviews, she rou-tinely sounds the alarm of the American obesity epidemic.21 Yet, unlike many obesity researchers, Nestle herself doesn’t stand to gain personally from labeling obesity this way—she is not on the payroll of any pharma-ceutical company. Instead, she employs this language as part of a politi-cal effort against major food corporations, such as Coca-Cola and Frito-Lay. By claiming that obesity is an epidemic, Nestle can argue that the political power of Big Food is adversely affecting Americans’ health.
She notes, “Obesity is the most serious dietary problem affecting the health of American children . . . the blatant exploitation by food companies of even the youngest children raises questions about the degree to which society at large needs to be responsible for protecting children’s health.”22 For Nestle, like many liberal critics, the idea of an obesity epidemic is a useful weapon in the battle against corporate political influence.
The idea that obesity is an epidemic disease is also reinforced by the professional cultures within the health programs of major research uni-versities and the health agencies of the federal government. The scien-tists and administrators for America’s health programs are largely trained within the same research institutions and same curriculum.
These institutions instill particular ways of analyzing health problems, particularly with regard to larger populations.23 Health outcomes are seen in aggregate trends rather than in terms of individual well-being.
Thus, if a certain percentage of people with a physical condition con-tracts a disease or dies, then anyone with that condition is seen to be sick. For example, because obesity is statistically associated with so many health conditions, it is often inferred to be a cause of disease. The drug industries also work to reinforce this “diseasing” through their spon-sorship of pseudoscientific health organizations such as the IOTF and their support of industry “thought leaders” who testify before govern-ment panels and lobby governgovern-ment agencies on behalf of particular views. Points of view or perspectives that are outside of the public health paradigm often do not get represented. Skeptics such as Dr. Glenn Gaesser, Dr. Steven Blair, or Professor Paul Ernsberger often express their frustration with getting alternative points of view acknowledged.24 This professional bias toward characterizing obesity as a disease was particularly evident in the response to the April 2005 JAMA article by Kathryn Flegal that radically reduced the estimated number of deaths due to obesity. Rather than embrace the findings as good news (after all, according to the new estimate obesity was no longer such a major killer), organizations such as Harvard’s School of Public Health and the CDC went on the offensive. Harvard’s School of Public Health, un-der the auspices of nutritionist Walter Willett, issued a press release calling the study “flawed” because of its methodology—although they were conspicuously silent on previous estimates that offered much higher mortality predictions that used even more problematic statisti-cal methods.25 They went on to host a one-day conference on May 26, 2005, in which the study was roundly criticized, mostly because they did not like its conclusions. The CDC issued a set of “talking points” to state health agencies that said, “despite the recent controversy in the media about how many deaths are related to obesity in the United States, the simple fact remains: obesity can be deadly.” Scandalously, the CDC presentation went on to assert, “we know obesity causes about 2/3 of