Happy Friday, and welcome to Food Fix. You all had so many good ideas for making feeding kids a bit easier day to day! I’m still sorting through them – will share a roundup next week. While we’re on the subject of feeding people, if you want to help the thousands of individuals displaced by Helene, here are two good options: World Central Kitchen, which is providing meals and potable water across the southeast, and the state-run North Carolina Disaster Relief Fund, which is providing grants to community-based organizations on the ground.
Food Fix runs on subs: This newsletter is made possible by paid subscribers. Upgrade today to get Food Fix twice a week – on Tuesdays we cover even more topics. This week, I wrote about how FDA Commissioner Robert Califf thinks ultra-processed foods drive “addictive behavior” and why that matters – a piece that sparked a lot of emails.
Send me your feedback! What topics should I cover? Or you can always just say hi: helena@foodfix.co.
Alright, let’s get to it –
Helena
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The case for defining what obesity actually is
Officials have been warning for decades that America’s obesity rate has been climbing upward at an alarming pace. It’s now common knowledge that obesity – formally recognized as a disease in 2013 – costs a whole lot, not only in terms of direct health care costs, but also productivity, longevity, quality of life, and overall public health.
Military leaders have warned us that obesity rates pose a threat to national security because it means fewer adults are physically able to serve. Pediatricians have raised alarm that they are increasingly seeing obesity-related conditions like type 2 diabetes and fatty liver disease in children.
Hidden behind all of this alarm, however, lies a peculiar fact: We do not have a precise clinical definition for obesity. The medical establishment has long defined obesity as simply high Body Mass Index (BMI) – 30 or higher – but this is a blunt measure based on nothing more than a ratio of height and weight.
You might have caught wind of the fact that the BMI as a concept has been increasingly under fire, not only for being imprecise but also problematic, if not racist – and because it’s ultimately not a measure of someone’s health, just their size. Unlike high blood pressure or diabetes, we lack biomarkers or other measures that are more specific.
Now that the U.S. is firmly in its Ozempic era, the fact that we lack a sophisticated clinical definition for obesity has become all the more glaring, according to health and science journalist Julia Belluz, who wrote a great essay on all of this for the New York Times last week.
“Diagnosis by B.M.I. was always imprecise; in an era of remarkably effective weight loss drugs, it’s untenable,” writes Belluz. “With new treatments that cost upwards of $1,000 per person per month, along with supply shortages, how to define obesity is more than just a fight over nomenclature. It’s about pinpointing who is sick and will benefit from health care and how to triage that treatment and most effectively allocate resources. It’s about ending the murkiness that has surrounded obesity diagnosis for decades.”
The lack of clarity, Belluz writes, “makes patients out of people who aren’t ill and glosses over those who need health care urgently. In declaring a disease without nailing down what the disease is, the medical community left obesity open to debate among doctors, insurers and everyday people. This in turn left people with obesity vulnerable, their bodies subject to accusations and questioning, overtreatment, undertreatment and mistreatment.”
If you’re not familiar with her work, Belluz is a must-read (seriously, go sign up for her newsletter so you don’t miss any of her work). I personally think she’s done the best reporting on obesity and the new class of weight loss drugs (GLP-1s), and her writing has helped me understand the complexity of this new era we’re in.
I recently got to talk with Belluz about her essay, her recent reporting, and her forthcoming book on nutrition, metabolism and obesity – I hope you find it as interesting as I did.
The following conversation has been edited for length and clarity.
Helena: I noticed that Robert F. Kennedy Jr. – who I’ve been following closely because of his recent influence within the Republican party – criticized your New York Times essay on X for not focusing on the role of the food environment. What’s your response to that? And what has the overall reaction been?
Belluz: I agree with him about the food environment being the driver of diet-related disease. The best way to help everybody out of this and to prevent future illness is to clean up the food environment. But the piece wasn’t about causes or the broken food system – it was about the effort to define obesity the illness.
My editor says everybody wants every piece about obesity to be about everything. And that’s been my experience. If you write about X, people say, “but why didn’t you cover Y.” It’s a very sensitive topic.
I hear a lot from people who have struggled with obesity, who are happy to see coverage that doesn’t suggest it’s driven by a failure of will. At the same time, I tend to get a lot of letters saying the way to solve obesity is that people just need to stop eating so much. The science shows that obesity doesn’t arise as a result of a failure of willpower.
I know you’ve followed these issues for a long time. Have GLP-1s changed your thinking around obesity and nutrition? Has this new class of drugs changed our understanding of what obesity is?
These new drugs have highlighted a) how much we still have to learn about obesity, but also b) how much the medical community still hasn’t done its job, you could say, of doing things like having a proper clinical definition for obesity.
Yeah, I didn’t know how complicated this all is. It’s much more complicated than it seems.
Yeah. Right now, the way you diagnose obesity is largely based on BMI. This question: what is obesity, the disease? This is not answered in the medical community. It’s crazy. It’s a condition or disease that’s been with us for so many years, and there’s still so much more we have to learn about it. The scientific community has advanced, but that’s not at all reflected in terms of the public understanding of the disease, the overall policy debate, or clinical questions, like: Who needs treatment? How do we access care? How do we triage care? There’s this broader failure.
And now you hear everyone saying, “Of course obesity is a disease, it’s a disease. It’s a disease.” But when you peel back the layers and look in the medical literature, there’s a raging debate about this. The debate isn’t about: Is this a real health risk, it’s about demarcating what the illness is and what it isn’t. How can we have something more precise than just BMI, which was never meant as an individual diagnostic tool? There is now a forthcoming Lancet Commission on this topic of, how do you actually define clinical obesity?
(Editorial note: I refer to obesity as a disease because of the American Medical Association’s designation. It’s also AP style. Belluz, however, still wrestles with this, writing last week: “the more I know about obesity, the more the D-word gives me pause. Excess fat is the defining characteristic of obesity, linked to sickness and death since antiquity. But modern science tells a more nuanced story.”)
It really is wild that this isn’t more defined. This is a disease that affects more than four in ten adults and two in ten children in the U.S.
Not having a real definition is how you end up in all these debates: Is it a disease, or isn’t it? Are we unnecessarily medicalizing people? What’s the role of willpower and personal responsibility? We never decided what is this disease, actually? I think once we have this definition, that will help. Are people having political debates about things like cancer and whether people need treatment? No. Once we have a definition, maybe we’ll all sort of grow up about how we talk about this.
Maybe, but we’re still openly debating what’s caused the obesity epidemic — there isn’t consensus about that either! Even though diet and exercise are, on average, not an effective intervention for obesity, we still cling to this idea as a society that if only people with obesity just ate healthier or ate less they could reverse this disease.
There’s so many interests that have minted billions of dollars off of us believing that, right? If we just buy the one book, or we just start the new self-exercise regime, our problems will be solved. It’s looking much more like this is an environmental problem. It’s not like humans just lost willpower. Do you really think large swaths of humanity just gave up?
In the food world, one angle that’s been interesting re: GLP-1s is the mild panic among business leaders about the potential impact to food demand. We’ve seen some early indications that being on one of these medications shifts food purchases. Have you thought about this? Do you think we’ll ever see enough patients access GLP-1s for there to be a broad impact to the grocery or restaurant market?
I don’t have anything more than speculation, but there are huge access issues. There’s a lot of media coverage of Ozempic. But does that mean everyone’s taking the drug? No. Among the patients I talked to, and I’ve talked to many of them, it’s not a linear experience where they take one drug, they stay on the drug, they lose weight, they change their eating habits, and their eating habits are just permanently changed. It’s more that they take the drug, then their insurance changes, they have some issue with access, maybe it’s in shortage, etc. Then they switch drugs, then they come off the drug, and then they regain the weight, and then they go on another drug. I’ve found that to be much more representative of the patient journey.
Let’s say we solved the health system problems and the supply problems and the problems with access and everyone who wants one of these drugs starts to take one. Even then, I think history has shown us that the food industry adapts. They reformulate. Maybe people are eating fewer Oreos, or whatever it is, but maybe they’ll be eating more yogurt. Even if people eat fewer calories overall, that doesn’t necessarily mean less profit. Maybe it means higher margins or more premium products.
The other big complaint I hear is that this cop out that we should be focusing on changing the food system instead, changing the overall food environment, to get at root causes instead of spending so much time, energy and money treating the symptoms. What do you think about that?
The way I think about it is that these are treatments for people who already have the condition, the same way bariatric surgery is a treatment. Ozempic is part of the medical treatment diagnosis discussion for helping people who need help now. When you go more and more upstream, getting at root causes, that’s a question of prevention. That’s where you look at things like the food environment and making access to healthy foods equitable and sustainable, and all of those things.
I’ve been covering obesity for about a decade. Basically no one cared about obesity beyond trend diets, intermittent fasting, low carb, whatever it was – that was the only way you could sort of get into the public interest on weight related issues. That was the public discourse. Now what I’m seeing is way more sophisticated public discussion about obesity as a disease, in part because we now have scalable and effective treatments.
Tell me about the book you’re working on. I can’t wait to read it.
It’s about the history and present of nutrition and metabolism science and how much of the advice the public has been getting has been based on half truths, untested ideas and half-baked science. I’m co-authoring it with Kevin Hall, who is this amazing scientist on these issues.
If you’re interested in these topics, sign up for Julia Belluz’ newsletter for updates on her work and forthcoming book.
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What I’m reading
We may have passed peak obesity (Financial Times). “Around the world, obesity rates have been stubbornly climbing for decades, if anything accelerating in recent years. But now newly released data finds that the US adult obesity rate fell by around two percentage points between 2020 and 2023,” John Burn-Murdoch writes in a fresh column this morning. “We have known for several years from clinical trials that Ozempic, Wegovy and the new generation of diabetes and weight loss drugs produce large and sustained reductions in body weight. Now with mass public usage taking off — one in eight US adults have used the drugs, with 6 per cent current users — the results may be showing up at the population level.”
Ports’ strike ends, as dockworkers reach agreement on wages (NPR). “The strike by tens of thousands of dockworkers on the East and Gulf coasts has been called off, after the International Longshoremen’s Association and the United States Maritime Alliance, representing ocean carriers and port operators, reached a tentative agreement on wages,” reports Andrea Hsu. “The parties have also agreed to extend the existing contract until Jan. 15, 2025. In the meantime, they will return to the bargaining table to negotiate all other outstanding issues, including the union’s demand of a ban on all automation at the ports.”
Ozempic goes from threat to opportunity for packaged-food makers (Bloomberg). “Big Food is warming to Ozempic,” writes Deena Shanker. “Less than a year ago, the head of Novo Nordisk A/S was fielding calls from ‘scared’ food industry executives about his company’s blockbuster drug that suppressed cravings, and survey data suggested sales could be hurt by lower consumption. Now with a better view of how the medication is affecting behavior, packaged-food companies are trying to profit off of the Ozempic craze.”
Austin company Siete Foods to be purchased by PepsiCo (KVUE). “PepsiCo announced a $1.2 billion agreement to purchase Siete Foods, a Mexican-American brand that sells chips, tortillas, sauces and more. The deal is expected to be officially approved in the first part of next year, with limited specifics available at this time,” reports Morgan McGrath. “Siete, or Garza Food Ventures LLC, was created ten years ago in South Texas by co-founder Veronica Garza. As a teenager, Garza was diagnosed with multiple autoimmune diseases, including lupus. In order to combat her health struggles, she worked alongside her mother to produce unique recipes, eventually crafting an almond flour-based tortilla. Ten years later, the thriving business offers a wide variety of healthy products, including grain-free Fuego potato chips, Cassava flour tortillas and Tangy Traditional sauce.”
Subpoenas issued to HHS and USDA for documents related to development of alcohol consumption guidelines (House Committee on Oversight and Accountability). “James Comer (R-Ky.) issued subpoenas to U.S. Department of Health and Human Services Secretary Xavier Becerra (HHS) and U.S. Department of Agriculture (USDA) Secretary Thomas Vilsack for documents requested as part of an investigation into development of the 2025 Dietary Guidelines for Americans. Specifically, the Committee is investigating recommendations related to alcohol consumption,” a press release states. “The Oversight Committee is concerned that despite USDA’s shared responsibility for formulating the Dietary Guidelines and the National Academies of Sciences, Engineering, and Medicine (NASEM) directive to study alcohol intake and health, HHS appears to be taking improper authority over the development of the alcohol consumption guidelines.”
Senators Markey and Booker urge FDA to ban toxic phthalate chemicals from use (Senate). “Senator Edward J. Markey (D-Mass.), member of the Environment and Public Works Committee, and Senator Cory Booker (D-N.J.) today sent a letter to Food and Drug Administration (FDA) Commissioner Robert M. Califf urging the agency to ban phthalates — chemicals commonly used in food manufacturing components and fast-food packaging, which enhance the durability, flexibility, and transparency of plastics — from use in food contact materials (FCM),” per the press release.
Cutting food waste would lower emissions, but so far only one state has done it (The Associated Press). “The difficulty of cutting food waste has spoiled several states’ attempts to ban it, and only one — Massachusetts — has actually succeeded, according to a study this month in the journal Science,” writes Melina Walling. “Massachusetts did it by building one of the most extensive composting networks in the country, inspecting more often, keeping the rules simple and levying heavy fines on businesses that don’t comply, the study found. That matters because food waste contributes over half the planet-warming methane emissions that come from landfills, according to the Environmental Protection Agency.”
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