





Guest post by Jennifer Calihan at eatthebutter.org








Seven Ways Money Buys Thin

1. More Money Buys Better Food



















5. More Money Buys a ‘Culture of Skinny’







7. More Money Buys Bariatric Surgery


Another Inconvenient Truth





The Vintage Alternative













Figures from the author’s comments in the comment section below:

King county king county obesity



70 thoughts on “Low Fat, High Maintenance: How money buys lean and healthy–plus, an alternative path to both

  1. @calihanje, I couldn’t reply to your comment above (I think we nested too much already), so I put my answer here.

    You can find more data (more countries, more detailed breakdowns of income) to see if your impressions hold up. I used Google image with income + obesity. Here are a few I found.

    In Canada, there is no trend at all between obesity and income (5 categories of income) when looking at both men and women together.
    See table 4.3 here, about three quarters down the page.

    In Brazil, the trend is similar to the US, that is, rich women are leaner (and only the very richest ones at that), but rich men are fatter.

    In the UK, it seems that only the richest women are somewhat leaner (and not that much). No trend for men. Scroll down to see the image of obesity vs. income in this article.

    In Canada again, young adults only. Downward trend for women, upward trend for men.
    Scroll down to figure 3.16.

    On top of contradictory trends, I hope you also notice that obesity is never *rare*, in any income category. It may sometimes be somewhat lower, but money does not guarantee leanness at all.

    It seems to me that your “bubble” is more an anecdote than data.

    Now, we still have to explain why some zip codes have much less obesity than others. My first guess would be that wealth, neighborhoods and BMI all depend quite a bit on what your parents passed on to you (their money, their origins, and their DNA). Add some spouse selection (rich men marry beautiful (= slim) women) and I think that covers the gender differences.

    Maybe you would also be interested in the work of Schelling about segregation. Basically, a slight preference to be surrounded by people like oneself can lead to dramatic differences in neighborhoods.

    1. I think the point of the post was to provide one woman’s observations, not data. Just as one woman’s observations won’t tell the “whole” story, neither will data.

      Charlotte Biltekoff’s excellent book, Eating Right in America, has a chapter dealing with the social, cultural, and historical underpinnings of the “obesity epidemic.” She states, “The construction of obesity as a health crisis may have in fact hinged on its historical association with people of color and the poor” (p. 140). Whether real or perceived, the idea of “poor/minority obesity,” according to Biltekoff, has “fed into the stigma at the intersection of race, class, and body size” (p. 141).

      Helen Viet notes that this intersection of stigma around race, class, and fatness arose in the early 1900s the the Progressive era, as “Americans made increasingly bold associations between moral righteousness, physical self-discipline, and the unattractiveness of body fat” particularly for women (p. 8). Prior to this time, Viet notes, some body fat was an indication of prosperity [this may still be the case in some cultures]. Thus, as Gloria Steinem pointed out, that which is available to those in power is that which is considered desirable–either fatness or slenderness.

      We know there is no question that slenderness is considered more desirable in our current social context; but there are other questions that this discussion then raises for me: Is it really more “available” to those in power (i.e. the very wealthy), or not–and who are the people “in power” here anyway? Or is the concept of obesity as being associated with the poor and with minorities (and where these populations intersect), just that, an association, but not a reality? Or perhaps, in the ever-widening income gap between the 1%ers (or 5%ers) and the rest of America (or the world) is the slenderness of the very rich a way of setting themselves apart from the ever-widening waistbands of even upper/middle income groups?

      I will add, that from my reading it seems that, for the very wealthy, the social pressure to maintain a slender body size may be especially intense–particularly for women–and yes, we are talking about white people here because (as Jennifer notes) that’s who the very wealthy disproportionally are.

      Charlotte Biltekoff suggests that “one did not need to conduct a survey to see that the affluent upper middle class was terrified of becoming fat and was aware of its social implications, which threatened both race and class status. Fatness remained a marker of inferiority that threatened to strip members of the white, affluent middle class of their class and privilege” (p. 144).

      If this is so for the “white, affluent middle class,” how much more so for those in the “bubble”? From Biltekoff’s perspective it seems that it would be a rare thing, in our current moral panic about obesity, to find very many extremely wealthy individuals who are fat.

  2. “In the Third World, the rich are fat and the poor are thin. In the First World, the rich are thin and the poor are fat”.

    Some fascinating information here both in the post and in the replies.

    I live in a small market town in the UK, surrounded by other small market towns and villages, in an agricultural area. We still have two butchers and two vegetable shops in town, and although many of the village shops have closed they have been replaced by farm shops – in all of them the food is largely traceable, you can find out which farm the produce comes from and even the name – or number – of the specific animal you are eating.

    Here the stratification is principally age – the fit healthy old folks who are mainly found in said butchers and veg shops, eating fresh local food, and the middle aged fatties with other metabolic diseases who can be found in the supermarket buying their “low fat!!!” food and becoming inevitably fatter and more ill (this includes several doctors and nurses).

    It struck me recently that the people who remember a time BEFORE low fat diets became the default are now dying out, after which Conventional Wisdom will be home free. Most of the “Healthcare Professionals” will never have known a time when there were no “epidemics” of obesity, diabetes and other metabolic diseases.

    My mother lived to be 95, her cousins 88 and 91, her own mother 90, a neighbour was 108. Most of my friends, neighbours and relatives thereof who have died made it into at least their eighties, and you can find octogenarians dating back a couple of centuries in the local churchyards. Dig them up and ask them and you would probably get the same answer as from the still living – “None of that low fat rubbish for a start!”

    The other side of the coin comes from the farmers. The major crops are wheat, oilseed rape, sugar beet, potatoes, barley and peas for freezing. Carbs and margarine! Yet despite their 400hp tractors, 600hp combines and 30m sprayers there are years when they make a massive loss, wheat may sell for £50/tonne LESS than the cost of production, though they may do well in good years: The profit from these “foods” is all accrued by the middlemen. Which pretty much explains why you are told to eat more of them at the expense of Real Food, the growers of which may not make the same profits but don’t make the huge losses either.

    Eating Real Food may initially appear expensive, but it becomes significantly less so when you realise you no longer have to stuff your face with cheap carbs every couple of hours. Add in all the drugs you no longer have to take (antidotes to the diet like statins, BP meds, PPIs etc.) and ensuing medical procedures like stents and amputations, and the fact that you are supporting the local economy rather than shareholders, and you begin to see why the recommendations are what they are and the results are what they are.

    1. The age stratification is interesting. In clinic, when we would put folks on a low-carb diet, they would often say, “Oh you want me to eat like back on the farm!” And yes, I’m afraid those folks are dying out.

      Gloria Steinem has an excellent essay published in earlier in the same year the first Dietary Guidelines were released, 1980. She says, “What is rare and possessed only by the powerful is envied as a symbol of power.” In poor societies with little food, plumpness is valued. She goes on to add, “In more fortunate societies where women become plump on starch and sugar if nothing else, leanness and delicacy in women are rare and envied.”

      More than once in my recent reading I have come across the statement that, historically, diets of the poor in the U.S. (and perhaps elsewhere) are high in starch, sugar, and fats/oils. Switch out “sugar” for “fruit” and make sure your fats are oil, and you pretty much have the Dietary Guidelines.

      I really like your farm-to-pharmacy perspective!

      1. Looking at the input into the system is enlightening.

        Many/most of our farms are family owned small businesses. The return on capital they achieve is appalling. The subsidies “paid” to farmers actually go straight to the “Food Industry” in the form of reduced costs. The excess profits made by said “Industry” serve to bankroll dietary authorities, health “charities” and the marketing thinly disguised as “scientific research” they produce. The wheel turns. Any executives of Coke, Kelloggs, Kraft etc. who produced the sort of return on capital taken for granted by farmers would be sacked for gross incompetence.

        The drug companies grow rich on producing antidotes to the appalling dietary advice, which gives even more money to back the current Conventional Wisdom and drown out the ever increasing amount of Real Science.

        Either you can earn enough to spend enough to overcome the harm – like diabetics who can afford insulin pumps, home gyms and Personal Trainers – or you can subvert The System by reverting to eating what people ate before there were “epidemics” of obesity, diabetes and other metabolic diseases, in the process supporting the local economy free of parasites. That would be nice . . . sorry, am I ranting?

        1. I’ve been doing some reading on the economics of the food system. It’s pretty ugly, especially for the smaller farmers–and it gets worse when you look at it globally. Basically, farmers take the risks and producers make the profits.

          And, yes, for consumers there seems to be a similar pattern. The wealthy can make any diet work, and the poor can’t afford any diet but one that will turn you soon enough into a patient. I don’t know what it will take to reverse the process our nutrition guidance and food system have been headed in for the past 40 years, but certainly a rethinking of what a “healthy diet” might be is the place to start.

          Ranting welcome. Always.

          1. Yes, both the end users and the producers suffer. A friend was a farmer. He needed a bank loan to renew a load of field drains so he could increase his income back to where he could repay the loan. The bank manager refused. He sold the farm and became a millionaire.

            Another, a dairy farmer, said “If I went to my machinery dealer and said “I’m having that tractor, and this is what I’m paying for it!” they would laugh and throw me out of the showroom. Yet that’s what the supermarkets do with my milk.”

            A new dairy farm just started up down the road. They put in enough capital so they could deliver their milk direct to local outlets and also process it into cream, cheese and ice cream. That cuts out the middlemen, and their shareholders.

            Yet another grew asparagus. He employed East Europeans to harvest it and stored them in caravans, then after the picking season he let the caravans as holiday homes. Then he worked out that he would make more profit letting caravans all year, and the asparagus went away.

            A local pub specialised in local food, including stuff he grew and reared himself. He was so successful that the brewery doubled his rent. Most other village pubs that have stayed in business do something similar.

            There’s grass roots food as well as grass roots health. And on the other hand there are profits 😦

            A doctor who has been using low carb diets for his diabetics claims to save between £10 000 and £30 000/year. Obviously if all doctors did this, drug companies would go bankrupt (I believe there are currently something like 70 “new” diabetes drugs in the pipeline, but next to no new antibiotics). Which is why doctors are tasked NOT to do this.

            What we desperately need is evidence-based food and evidence-based medicine – but based on REAL evidence, not thinly disguised marketing. It’s all there, hidden in plain sight on PubMed, and growing exponentially in the last decade or so, and curiously pointing back towards what was known long before “low fat”.

            1. As someone who keeps being tossed into the digital media scholarship pond without a float, I’ve had to temper my optimism that the wealth of information available to the public will somehow accelerate the change I’d like to see. I just have to keep reminding myself, for every person who looks up an actual study on PubMed, there’s five who forward a Food Babe post to all of their friends.

  3. Wow. I’ve been thinking about this post for a week and every time I think I’m ready to comment, I feel like I have to think some more. Enough. Time to talk.

    Jennifer, your website looks great and is a welcome addition to what I call the alternative nutrition landscape.

    But . . . I’m not sure you see things clearly.

    Your post wonderfully points out how Thin is IN. We all know this. And that rich people have it much easier when it comes to being thin.

    But thin is not necessarily lean (low or normal body fat) or healthy!

    I think you’ve given your crowd on your side of the football field an undeserved halo of health, just because they are thin. How do you know how healthy they really are? Can you see their hypertension, dry skin, high HbA1c, insulin resistance, arthritis, orthodontics, visceral fat, osteoporosis, fatty liver, leaky gut, brain fog, etc?

    Sure, perhaps as a group your side of the football field might be relatively more healthy, but going by visible perceptions of weight is a poor marker. There are lots of thin diabetics.

    Thin people often have abnormally thin hips and faces/skulls/jaws. After having learned about Weston Price and the healthy wide, broad faces of those cultures who ate traditional non-western diets, I can’t help but think of the poor nutrition that may have contributed to those with abnormally thin faces.

    Thin yes, healthy no. We can do better than thin. Focusing on thin or skinny misses the point. Both sides of the football field are so unhealthy.

    1. Hi Kenny, so good to hear from you! It is true that body size and weight are imperfect and often fallible measures of health, but I’m afraid that money buys health too. The “health gap” based on socioeconomic status is, I think, even more distinct that than of weight. WHO puts it succinctly, “Life expectancy is shorter and more diseases are more common further down the social ladder in each society.”

      But I think you make a good point about less visible issues. I wonder if the population as a whole–on both sides of the football field–is aging poorly relative to past generations. Life expectancy continues to increase, but I wonder about life quality in later years.

      1. Hi Adele, great to be with you again! 🙂 2015 was tough, but I’m doing well in this new year. Been focused on earning a living, so finding time to read nutrition has been tough, but I’m determined to get back in the saddle!

        1. Well, I am about to disappear into the land of PhD again shortly. I know the feeling of being pulled between the work you “have” to do and the work you “want” to do 🙂

    2. Kenny, I am so glad you posted. You make a good point — thin does not always mean healthy, and you are correct that I have no idea whom among either crowd might have compromised health. In addition, obesity does not always mean ill health, either. Lustig says that 20% of obese adults are metabolically healthy; their weight does not affect their lifespan.

      That said, eating higher quality food (especially less processed food), more homemade or homestyle meals, and exercising more all contribute to better health. Trying some alternative diets, like Paleo, low-carb, grain-free or WAPF, should also improve your chances of good metabolic health (IMO). Paying more attention to what you eat (because of the culture of skinny) and having more ways to treat yourself (outside of the food realm) can’t hurt. Finally, bariatric surgery can improve metabolic health. So I think it is fair to say money buys not only thin, but healthy, too.

      Here is an article from Diabetes Care, circa 2007. (https://www.researchgate.net/profile/K_M_V_Narayan/publication/255654117_EFFECT_OF_BODY_MASS_INDEX_ON_LIFETIME_RISK_FOR_DIABETES_MELLITUS_IN_THE_UNITED_STATES/links/541abc1a0cf25ebee988bd51.pdf) In essence, 45 year old women who are thin/normal have a 11-14% chance of developing diabetes; overweight women have a 30% chance. Obese women have a 46-62% chance of developing diabetes. So BMI turns out to be a huge risk factor (~4X) for diabetes. I will ask Adele to post the table in the notes — it is broken out by race and gender.

      Carb-Loaded is a smart, funny documentary that talks about diabetes risk, even for thin people. You might enjoy it if you haven’t seen it. It skewers the low-fat diet nicely.

      I sense you are worried about the people who are getting to thin by eating a very low-fat, almost vegan diet. Although it feels like the opposite of the wisdom of WAPF, I am open to the idea that it may be a healthy path. After all, these diets ditch sugar, white flour, and vegetable oil — three dangerous food types! Denise Minger, typically a high-fat advocate, (she wrote a scathing review of T Colin Campbell’s pro-vegan book, The China Study), has recently blogged about the ‘magic’ of diets with both very low-fat contents and very high-fat contents. She contends that the trouble lies when you are stuck in the middle. You might find her extremely long post interesting. (http://rawfoodsos.com/2015/10/06/in-defense-of-low-fat-a-call-for-some-evolution-of-thought-part-1/) President Clinton’s doctor, Caldwell Esselstyn, published some impressive results with his very-low fat almost vegan regimen in a recent paper. (http://dresselstyn.com/JFP_06307_Article1.pdf) I am openminded, but feel compliance is an issue for many eaters. I’m happy that there is ‘magic’ at the high-fat end of the spectrum, too!

      The people who are skinny because of good genes but spend their days eating junk and drinking diet soda are the thin folks I worry about. That holds true on either side of the field, definitely.

      1. Jenni, thanks for the thoughtful reply! Part of me wants to welcome you and part of me wants to see what you’re made of. 😀 Putting your post on Adele’s blog means I’m used to throwing stuff at Adele because I know she can take it and dish it out, and that she’s a smart cookie and been at this a long time, as have I. I’m starting my nineteenth year of low carb eating this year, so I like to think I know a fair bit.

        OK, let’s say I accept your thesis that money buys thin/lean/health, then what? Are you going to make everyone rich?

        Madam, I’m sorry your first choice (being rich) is unavailable to you at this time. Please accept your second choice of “just eat real whole food”, meaning you just have to learn about food, then do a lot of Shopping/Cooking/Cleaning to feed yourself and your family, instead of living a much easier and more convenient life like your first choice would have given you.

        But actually, your alternative path is the primary path that many alternative nutrition plans promote: Just eat real whole food!

        Unfortunately, this means you have to learn about food, then Shop/Cook/Clean – all highly inconvenient and fairly incompatible with the way many of us live, or want to live. Can people change their habits to cook more? Yes, but will they long-term? Doubtful. Not when we’re surrounded by endless attractive treats and tasty foods, all promoted by wall-to-wall advertising. That’s partly why I try to never watch TV commercials.

        From my own experience, I know that I won’t consistently do the Shop/Cook/Clean, no matter what the promised benefits are. I’ll find other ways to get much of the benefits without all the work.

        As for Denise Minger. I’ve read her book and it’s good. But I think she continues to believe too much in nutrition epidemiology and her ability to tell the “good” studies from the bad ones. Except they’re all bad. See Alice and Fred’s discussion of the tragedy of the “new epidemiology”, http://ketopia.com/new-epidemiology/

        And vegan diets? I don’t understand how you get around the fact that they lack some essential nutrients, and that no native indigenous peoples have ever been found to be exclusively vegetarian, let alone vegan. I prefer to eat the most concentrated nutrients I can, which means focusing on meats and fats. Vegetarian and vegan diets usually mean high-carb diets, which will rot your teeth, as Denise Minger learned. Leaving proteins and fats on your teeth won’t rot them. What’s good for your teeth is probably good for the rest of your body.

        Finally, a request if I might. I looked through your website and really enjoy the visuals. But what I think would really help is a deeper section on who you are and why you care about this issue. What’s your story? That’s what I always look for and didn’t find, and I think that’s what people really want to know before they start believing you care. A few months ago, Nina Teicholz somehow stumbled across my tiny obscure blog and sent me a nice note asking me what’s my story. She wanted to know because she said I had some good info on the blog. It made my day. 🙂

        1. Hello again. Unfortunately, I will never be as smart or funny (or as tough) as Adele, but that does not mean we can’t have a constructive back-and-forth! And I do feel welcomed — thanks for checking out my site. What is your blog called? I would like to reciprocate.

          Thanks for the article link. It was good. I have used ice cream consumption rates and drownings to illustrate the correlation/causation point, but skirts and breast cancer is a better way to say it.

          Your “Madam, I’m sorry your first choice…” quote made me laugh. Alas, everyone can’t have endless time and money for eating right and exercising. That was part of the point of the post, as I am sure you are aware. What I am trying to do with ‘Vintage Eating’ on Eat the Butter is to repackage alternative (mostly ancestral) eating ideas into something a non-food and non-science oriented mother might find appealing and approachable. I have no ‘scientific chops’ but I am trying to bring what I do have: complete confidence in the ancestral perspective, a decent sense of what it is like to cook for kids for 20+ years, an ability to curate others’ ideas, an informed perspective on how corporate interests come into play, an ability to express myself, and a modest budget for trying to say what I have to say to as many mothers as possible. A rising tide floats all boats, so I hope Eat the Butter can bring more mothers to the real-food-more-fat table, and that that will be good for the community of experts selling more detailed plans and cookbooks.

          Many mothers are busting it to make low-fat meals for their families. If we could just get them to flip the ‘fat is bad’ script in their heads to ‘sugar is bad,’ all that work they are already doing would pay much greater dividends. Breakfast is an obvious example. If Special K, skim milk, and orange juice could no longer be sanctified as the epitome of a healthy breakfast, there are lots of moms who would be willing to spend 4 minutes frying an egg. Mothers are pretty motivated to do what is best for their children; we just need to redefine ‘best.’

          Author and science journalist Ann Gibbons is a personal friend; her thoughts have influenced my willingness to accept that many ancestral diets contain a lot of starch. Check out her National Geographic piece, The Evolution of Diet, here: (http://www.nationalgeographic.com/foodfeatures/evolution-of-diet/) We know that meat was often scarce — so an almost vegan diet doesn’t seem completely anti-ancestral to me.

          We also know that almost vegan diets, when compared to standard low-fat diets, protect against obesity, diabetes, and heart disease. Might they increase cancer or depression or stroke? I have no idea. I am committed to spreading the word about real-food-more-fat, not opining on all dietary options. So, as I said, I have an open mind about those who choose to minimize animal products for various reasons. And, as you point out, I hope they are supplementing those missing essential nutrients carefully.

          As far as more about me on the site, I’ll try to do that. I have heard that from others, too, and I know people connect more when they hear your story. Perhaps I hesitate because I ‘forgot to have a career.’ It is probably my own insecurity, but I fear that people dismiss the thoughts of long-term stay-at-home moms, even if they have impressive educations (and thus once had a competitive voice)… makes me hesitate to emphasize my story, I guess.

          1. I wouldn’t worry too much about not working. I spent a decade being essentially a bum with internet access (so I could read and learn about nutrition). I have no formal education in nutrition whatsoever, just an intense interest.

            From your website and your post and comments here, I can see that you have the skills needed, namely, good communication and writing skills, along with good public speaking skills. And by your appearance on Adele’s blog, you know how to make connections with the right people.

            As for my blog, just click on my name at the top of this message or any of my posts here.

            For telling your story, all I’m really looking for is what made you change to the way you eat now? When? Why? What was your eating pattern before? What made you change? What benefits do you get from the way you eat now? How did you discover a better way of eating? What was the transition like? Who did you learn from and what lessons have you learned? Was it easy or hard? Was it worth it? Why? That kind of stuff.

            In brief, I started strictly following the Food Pyramid in the mid-90s. I wasn’t even trying to lose weight; I just wanted to eat healthier. Well, the low-fat diet turned me into a pre-diabetic with insatiable hunger, unquenchable thirst, extremely dry skin, among other maladies. I said to myself, this can’t be right, and searched for a better way, eventually finding the Protein Power book and the low carb way of eating. Low carbing was a revelation, as it cured all my ills and made me feel so much better. There were so many predictions that low carb diets might work for short-term weight loss, but surely you were just asking for heart disease later. Well, it’s later now, and I’m fine, so all that saturated fat hasn’t managed to kill me yet.

        2. Jenni, I agree with Kenny about hearing more about “your story.” I know (at least part of) it, and I think it would make for very interesting material. You have a unique perspective on this matter, as your post demonstrates.

    3. Yes agreed. Genealogical research shows that one side of my family is bimodal, there are all these healthy long-lived folks and the others, like me, who remain skinny but have all the metabolic defects of obesity. It’s known as “skinny fat”, Michael Eades has called it “metabolic obesity” and someone (can’t remember who) called it “lipodystrophy lite” in that we go through all the steps of gaining weight except for stashing the excess food in our fat cells, so our blood remains full of excess glucose, insulin and lipids and we get hypertension too.

      It took real dedication from a dietician, carefully deleting all fat from my diet and replacing it with “healthy” carbs, before I finally gained weight so she could then accuse me of “failing to comply” with the diet.

      There are similarities with MODY forms of diabetes except the distribution within the family, it strikes mainly but exclusively males who die prematurely, as I will, from CVD.

      I spent decades wrecking myself with excess carbs and dutifully eating “low fat” just as I was instructed. Meanwhile all my symptoms of diabetes and diabetic complications were written off as psychiatric in origin or completely made up. I was over fifty when a GP finally thought to check my postprandial blood glucose. I’ve spent the last decade or more keeping my BG, BP and lipids in check by eating the exact opposite of what I was told, and been so successful I was recently told there was never anything wrong with me. Of course my premature death will be blamed on the years when I ate “too much fat” and not enough starch, and the decades when I ate too many carbs will be ignored.

      Estimates are that 5 – 20% of “Type 2” diabetics are non-overweight, the real number will never be known so long as doctors believe the same as the rest of the public, that diabetes is caused by being fat and obesity is caused by eating fat. I know enough people with a similar syndrome to suspect the 20% figure may be accurate.

      The other side of the coin is that some of the plumper people in the family were healthier, again not uncommon.

      Joseph Kraft understood all this decades ago, but how many current doctors have ever heard of him, let alone John Yudkin, Peter Cleave, Weston A Price and many others whose work was bulldozed out of sight by Ancel Keys and the Lipid Hypothesis/Diet-Heart Hypothesis?

      1. Chris, your personal story is a compelling one. Type 2 diabetes is exploding, and although it is much more common in people carrying extra weight, everyone should be looking for it. Blood sugar meters cost $10 on Amazon, and strips are about 17 cents each… so in theory, we all should be able to test our fasting blood sugar and our postprandial (after a meal) blood sugar. The fact that there are 77 MILLION Americans walking around with undiagnosed prediabetes is shocking. Time for some community screenings, don’t you think? Perhaps we need to start ignoring our ineffective federal health initiatives and going local with solutions.

        I am so glad you have identified your health issue and taken steps to minimize the damage. Thank goodness you have the confidence to eat pretty much the opposite of what you are told to eat. Here’s to many more low-carb years!

        1. Sadly, there is already a move afoot to increase screening for undiagnosed diabetes–all the better to get folks on meds and a low-fat diet right away!

          1. I wonder how we could flip that script? As in, the ADA’s script of heavy reliance on drugs to control blood sugar in prediabetics and type 2 diabetics rather than diet…and providers’ tendencies to ignore the ADA approved low-carb option and go straight to the ‘moderate, balanced diet’ approach (plus Metformin, of course). This ADA article from 2011 reveals their confusion… (http://www.diabetesforecast.org/2011/mar/are-carbs-the-enemy.html) Have they made any progress in the last five years? What could get them to make progress?

            1. I think where this is another area where it is going to take patients educating their healthcare providers for things to change–rather than the other way around (the comments to the article you linked are pretty telling). MDs, RNs, RDs hold onto what they’ve learned during their training. Any “new” information is typically suspect–a “fad” or worse. And then there are the ideological commitments which supersede individualized care. Only patients advocating for themselves can change that.

            2. Reading their own forums for a start! They are surprisingly full of success stories, as are almost all diabetes forums, newsgroups and blogs, yet none of the successes follow the ADA diet.

              When John Buse was in charge, they backpedalled slightly on their diary recommendations and lost one or two major sponsors. They haven’t done that since.

              Around the same time this happened


              Meanwhile patients continue to produce 5 – 8% and sometimes over 10% improvements in A1c, let alone all the other improvements in weight, lipids, BP etc. while the ADA and all other national diabetes “charities” flog ever more expensive drugs from their sponsors which may produce 2% or less improvement at the expense of often horrendous side effects including but not limited to premature death.

            3. I second the “read their own forums” bit! It is really a little weird, isn’t it?

              I met Judy Barnes Baker when she was going through all that. So close.

        2. It is FOUND more often in overweight people because that’s where doctors have been trained to look.

          Policy here is to refuse meters and test strips to all but Type 1 diabetics and Type 2s when they get on insulin. Current policy also is to use ONLY A1c for diagnosis. As Any Fule Kno this produces a high level of underdiagnosis, which improves statistics but does naff all for the patients’ health.

          Even more compelling would be to look at insulin levels which often go south years before the BG is affected, and even more years before fasting BG or A1c are affected.

          Many doctors see diabetes as “always progressive” without understanding that it’s the treatment rather than the disease which causes the progression, so they see little point in early diagnosis. Then when they see successful patients they warn them about the “extreme dangers” of cranks on the internet telling them to eat more arterycloggingsaturatedfat and less starch. What, Ron Krauss, past president of the American Heart Association, is a CRANK???

          To be fair it isn’t really the doctors’ fault, they believe the dogma they have been fed and have no clue that alternatives not only exist but are documented in studies they are not told about.

          1. Thinking about it further, I was a victim of “you’re thin so you can’t be ill” syndrome, which is far from uncommon, though less common than the corollary “if you just lose some weight you’ll get better” syndrome.

            “You’re losing weight nicely!” may mean you ARE losing weight nicely, or it may mean you have terminal cancer, or adult onset Type 1/LADA and are pissing your body down the toilet.

            “Your LDL/cholesterol is coming down nicely!” may mean your diet is working or it may mean (as I found out last year) you have become hypERthyroid. Who knew that hyperthyroid would produce exactly the same drop in LDL as a statin?

            There needs to be a more nuanced return to looking at the “whole picture” rather than just seeing the end result of tests as indicating a drug deficiency.

            1. Attia touches on this in his TED MED — (https://www.ted.com/talks/peter_attia_what_if_we_re_wrong_about_diabetes?language=en) According to him, the lean with insulin resistance are more likely to progress to more serious illnesses than the obese with insulin resistance. So although excess weight makes you much more likely to have insulin resistance, he muses that perhaps weight gain might be the healthiest response to insulin resistance — as in, if you already have insulin resistance, your odds are worse if you are thin, because your body hasn’t figured out the least damaging way to deal with that. Interesting.

          2. It is so hard to understand the resistance in the community of diabetic doctors to a low-carb option. Although it may not be for everyone, to not offer it up as an alternative worth trying seems crazy to me. Some patients would rather give up carbs than have their disease progress. They should be encouraged to do so, not kept in the dark.

            1. The dogma states that diabetes is caused by being fat, and being fat is caused by eating fat. So “obviously” a low fat diet is the cure.

              When it inevitably fails the response is usually that patients are “failing to comply” or that “diabetes is always progressive” and the only answer is adding more meds to the more starch.

              Not surprising when you look at the sponsors of the ADA, AHA, AND and all equivalents in all other countries – they are mostly drug companies, margarine manufacturers and carbohydrate processors. Busy GPs rely on what these people feed them in the guise of “Evidence Based Medicine” and they literally have no clue as to what is hidden in plain sight on PubMed – unless they actually go look for themselves, and when you are beset on one side by increasing numbers of patients and on the other increasing numbers of accounting clerks and their Rules, where do you find time to read stuff you didn’t know was there?

              Peter at Hyperlipid


              has some interesting stuff about “Physiological Insulin Resistance” if you look in the sidebar. The picture I have is that IR evolved as an adaptive mechanism for nutrient partitioning and food storage, but that only works when it is subsequently switched off again so the stored food (body fat) can be metabolised – which never happens on a high carb low fat diet. This ties in neatly with Peter Attia. Leptin is also a major player and triglycerides (from excess carbs) block leptin from crossing the blood-brain barrier so the hypothalamus no longer sees the leptin signal telling you you have eaten enough and gotten fat.

              I have another theory too, that skinny people psychically transfer their excess weight to other folks who get fat without eating any more, but the nurse is coming by with my medication soon.

            2. The overconfidence/dogma at the top (ADA, etc.) is a big part of the problem… Thanks for the link to Hyperlipid link — a very interesting (and detailed) blog.

              Maybe we could psychically transfer the message that the ADA should indeed read its own forums. It seems like the cardiologists are better at this — that is, learning from their patients. So happy to hear Dr. Steven Nissen (head of cardiology at Cleveland Clinic) break ranks so publicly last month. The DGA as an ‘evidence free zone.’ He is not mincing words.

  4. Great article and comments! I’ve learned and enjoyed them all, and I especially like Stephen’s second paragraph.

    However, I think one glaring fact missing from this conversation is our government’s and universities’ agricultural policies. They encourage the production of all types of sugar but not vegetables. They think GMO foods and those sprayed with pesticides and herbicides are ok or, even good, to eat. The policies are based on a river of oil and not a full understanding of the biology in the soil. All of these have reduced the nutrition of our food and the health of our soils. We need healthy soils to optimize the nutrition of our food and, as a wonderful side effect, to sequester lots of carbon.

    And again, the richer of those among us will be able to more easily access those foods that have been grown in ways that improve its nutrition. These foods are more expensive and may only be available at farmers’ markets that are open during limited times and places. Thus, the farmers’ markets take more time and effort from which to purchase food.

    Many people and organizations are promoting better agricultural practices, which are actually regenerative agriculture. Some of these people include Elaine Ingham, Allan Savory, Joel Salatin, Greg Judy, Guy Brown and last but not least Ray Archuleta. Some organizations include Westin A Price, Paleo groups as a whole, many small farmer groups and the USDA’s Natural Resources Conservation Service. Yeah, one government group is amazingly flying counter to the established wisdom of the most powerful and thus influential. Here’s a 24 minute NRCS’s video: https://www.youtube.com/watch?v=9uMPuF5oCPA

    1. Oooh. I got to see Ray Archuleta speak recently. Boy, if I weren’t already doing what I’m doing, I would want to be a soil scientist!

      And about the USDA: it’s a huge agency. There are a number of within the agency where valuable work is being done; the Center for Nutrition Policy and Promotion, however, is not one of them.

      1. Man, am I jealous or what? I would love to see Ray give a talk in person. Watching him in the videos, he seems like a force of nature. I mean how can a bureaucratic in the middle of the second largest bureaucracy in America (our military is the first) have such a strong voice.

        By the way, I messed up. It is Gabe Brown not Guy. He started to practice some of the regenerative agriculture practices 20 years ago in North Dakota (brrrr). His motto is something like: we mimic nature so that she does most of the work and we then can sign the back of the check and not the front.

        One great example of the power of mimicking nature is his production of corn. He produces about 140 bushels per acre in the short ND summer with an average annual rainfall of 11 inches and no irrigation. While a visiting farmer from Missouri, produced only a little more per acre, but has a longer growing season and over 40 inches of rain per year and yet had to pay to irrigate his fields. So, yes, soil science is where it is at now!

        Oh and his friend runs a laboratory that works with farmers. He did not believe all of the hype that Gabe was saying. So, he personally came and sampled and tested Gabe’s corn. Yeah, it was chock full of all of the corn nutrients.

        Here’s one of his talks: https://www.youtube.com/watch?v=9yPjoh9YJMk

        Also Elaine Ingham’s first hour long talk in the following 3 hour video is great. https://www.youtube.com/watch?v=QMvpop6BdBA No fertilizer is necessary with truly healthy soil.

        1. Not to up the jealousy quotient, but I got to see both Gabe Brown & Alan Savory live and in person 🙂 [The alt-ag equivalent of Bruce Springsteen-Elvis Costello double bill.] I hang out with the right crowd.
          An unresolved tension in the local/sustainable foods movement is that whole local foods include animal products–because as Ray Archuleta is fond of saying (from Howard?): “Mother Nature never farms without livestock.” But then, the logical thing to do is to include them in the FOOD system as well, which goes in opposition to both health claims and moral stances held by many otherwise “back to nature” local/sustainable advocates.

          Thanks for the links!

  5. I think Valerie’s comment came closest to capturing my unease at this guest post. Structural inequalities and stigma, whether it be towards race, class (and yes, that includes the US), or weight is a major, chronic life stressor. Let me speak to the scientist in you – bodily response, more cortisol. More cortisol, more central adiposity. More stigma, more prejudice, more inflammation, more diabetes, more hypertension, more heart disease. And while I know that is not the sole answer to the differences between the home and away teams, the tone of this article struck me as rather patronising, and attached to a hefty saviour complex, without the insight I usually associate with this blog. I’m surprised that Adele signed off on this to be honest. While some of the points made are no doubt valid, this left me with a really sour taste in my mouth.

    1. It’s a difficult subject to discuss, and Jennifer and I went through a lot of back and forth about it. She will be the first to admit that from her “bubble,” the desire to “help” does indeed seem patronizing (I appreciate her honesty in telling the story about attending a workshop on obesity and food deserts–an event that would likely be limited to those with the time and resources to devote to such unpaid endeavors, but who “care.” I think she skewers her own earnestness in this regard very nicely: “Boy, were we – visitors to this world – going to prove that even in a food desert and on a budget, healthy eating was possible if we made wise choices.”) At the same time, I can assure you that our current public health nutrition programs for low-income communities come off as nothing more than “let’s convince poor people to eat like rich people” with exactly zero attention to the complexity of other issues that go into, not just eating, but as you pointed out, what your body does with the food you eat.

      I think you make a terrific point about cortisol, and one that is seldom explored in the scientific literature. As I mentioned to Valerie, I have some comments of my own to make in regard to her post, and one of them is about stress. To take one of Jennifer’s examples, if you’re the mom trying to decide between oatmeal (kids will not cheer) and Sugar Bombs (kids will smile and hug you), not only might you choose the latter for the reasons she mentions, but imagine the stress that goes into just having to make that decision. You’re damned if you do and damned if you don’t. Argue with kids? Guilt? Pick one. A recent dissertation at my university discusses how mothers must negotiate food-health decisions as they raise their children, and again, it seems to almost go without saying that for low-income mothers, such negotiations are circumscribed by very different concerns, ones over which they have less control, than they are for higher-income mothers. Lack of control, stress, cortisol–it’s all of a piece.

      In other words, I think you are highlighting one of the biological factors that goes hand-in-hand with structural inequalities and can contribute to poor health. Jennifer is highlighting sociocultural factors. Daisy Zamora, a PhD in nutrition epidemiology who has done some outstanding work on racial differences in response to dietary patterns, highlighted those factors. None of them provide a complete picture, as you noted. But we need to start thinking of these things as all inter-related. I don’t want poor health in any population attributed to cortisol and then “treated” with medications that reduce that particular hormone without any consideration of why that population may have higher levels of cortisol in the first place.

      Most of all, I think we need to keep the discussion going and open. Jennifer’s willingness to say what things look like from her place in the world is a welcome antidote to articles like this one in the Washington Post, Why we can’t get our obesity crisis under control, which suggests that the opposition that low-income and minority communities have to taxing “junk food” is nothing short of self-harm which policymakers should override. There’s no consideration of either biological or sociocultural issues that may be at play: hunger, stress-relief through food, convenience, dissimilar values about what constitutes a happy life.

      I’ll have more to say about this. Thanks for joining the conversation.

      1. Adele, my upbringing was poor working class, although with a good work ethic and strong principles. I thought the article was sensitive and insightful. Yes, it was a perspective from the other side of the rails, but Jennifer’s entitled to her say and I’m grateful that she tackled a sensitive subject with obvious kindness and a desire to help. I’d have a slightly different perspective, but I agreed with pretty much all of her article. We shy away from these subjects too often to avoid reactions such as Angela’s, which I think is overly sensitive.

        The working class were told for years to avoid fat and gradually did so, and now it’s sugar, with much better evidence. It will take much longer for the message to get through because the working class have less time and inclination to read health messages and more reliance on the Government. I think there’s also more short term thinking. If life’s grim, what’s good now has more appeal. Those with a long and comfortable life ahead of them tend to want to protect it and see the benefit of delayed gratification. Confidence is another issue. If you really think you know what you’re talking about, you’ll be stronger with your children and that tends to be the middle classes. However, poor people often have a lot more contact with Government and in the dietary field that’s disastrous. The dietary guidelines hit them the hardest.

        The last conversation I had with a nurse on nutrition resulted in her taking notes and borrowing my books. More commonly for the poor or working class, it’s to be on the receiving end of terrible advice.

        Jennifer has written an excellent article and provided links to a website that I found particularly useful. Poor people don’t need shielding from the truth and they don’t have a fit of the vapours when they hear it.

        1. Stephen, Thanks for such a thoughtful response. After a number of conversations with Jennifer through email and in person, I realized that the perspective from her “bubble” was very similar to what I was hearing when interacting with most of the professors (and many of the students) in my nutrition program. It is a perspective that gave us “make the healthy choice, the easy choice” for low-income populations, which is thinly veiled accusation that otherwise this population won’t make “the healthy choice” for themselves. So I encouraged her to write about what she saw from “the bubble” because we hardly ever get more than blame and moralizing from the folks (in their own “bubbles”) who make the nutrition rules.

          I’ve been in Washington, D.C. boardrooms with well-meaning health advocates (highly paid, white, thin, females) wringing their hands and talking about the “obesity problem” of those Americans “out there” (i.e. not them), and literally not recognized the picture of the working class populations that they evoked (I come from a solid middle class, southern, smallish city) as sort of pathetic, mindless dupes of Big Food. The parents my kids went to school with (downtown, majority-minority schools) were smart, hard-working, and cared deeply about their kids’ health and their own (y’know, pretty much like I did). They struggled to feed their kids “healthy” foods, but by golly they tried (same here). But it would disingenuous of me to act as if we were somehow “the same” when it came to resources and social capital.

          In America, it is difficult for us to have conversations about difference. I think that, while we really do believe that “everybody is created equal” (because they are), that this sometimes seem to morph into, “everybody is the same as me.” I see this enacted all the time in comments sections attached to articles on nutrition: “Just do what I do. It’s easy.” And whatever the advice is, it might be easy for some and impossible for others. Why pretend otherwise?

          The fact that we have imposed upon low-income and minority populations nutrition advice based on observations of the food-related behaviors of populations that are worlds apart from them is bad enough. Then we turn around and blame them implicitly or explicitly when this advice does not lead to the same health outcomes? Whether or not they “follow” the advice is beside the point. It was never meant for them in the first place.

    2. I appreciate your candidness and understand your point about a patronizing air. I was trying to avoid that, but knew it was a risk when discussing issues of money and privilege in this sort of detail. I am sorry that, for you, I failed to strike the right tone.

      The main point of this post was in the title — low-fat diets are high maintenance, and we should move on (or at least offer more options). But another point was to remind people who live in one of all the various bubbles out there of the privilege that supports their normal weight status. I think many people take their circumstances for granted, and, especially over time, stop ‘seeing’ some of their expensive habits, particularly in day-to-day arenas like diet and exercise. So hopefully, for some readers, the post served as a gentle reminder of those privileges, creating more understanding/less judgment. And, if one of Adele’s readers might be a nutrition policymaker who sees a lot of success with low-fat eating in his or her particular fancy neighborhood, maybe he or she might reconsider why that success occurs.

      I really like your thoughts about cortisol. It is interesting though — oddly, the bubble can house a lot of stress. Those working — doctors, lawyers, very senior corporate types, CEO’s of small companies responsible for making payroll… they have a lot of stress. And non-working partners have a lot of pressure too — to look a certain way (as discussed in the post), to be an excellent volunteer, to maintain an immaculate home, to groom the kids in a way that will get them into the best college possible (which can get a little out of control when there is endless money for lessons, tutors, club sports, etc.). I have not seen studies that look at cortisol levels among the affluent. I could see it going either way, I guess.

      1. Thanks for adding these thoughts, Jennifer. And good point about cortisol levels within “the bubble” as well as outside of it. (I am reminded of the Atlantic article on the Silicon Valley teen suicides.)

        I do think there are a few of my fellow students from nutrition epidemiology who may poke their heads over here once in a while. I agree–and hope–that this post may offer them a new perspective on how socioeconomic advantage translates into a health advantage..

  6. This reminds me of the time I went to jury duty in Arapahoe County, Colorado. The upper-middle-class people there were thin, but they also looked haggard, stressed out, and ten years older than they were. (And they were shockingly ignorant of constitutional rights and due process.)

    1. I supposed cosmetic surgery is the answer to all the stress and strain of counting calories and exercising? More stuff to spend money on.

      Sad about the constitutional rights and due process stuff, though.

  7. Jennifer’s bubble has been around for at least twenty years. The NYT did a three part article about diabetes back then. A new part was printed for three Sundays in a row. Each part was several full pages long. One theme was about how the poor were disproportionally effected by the epidemic of diabetes.

    The journalists interviewed several different poor ethnic groups Dominicans, Vietnamese, and others. They could only afford meat rarely. Their entertainment was TV and beer or chips or cookies or ice cream…. They could not afford anything else.

    On another Sunday, the NYT reported on the huge NY Bellevue Hospital. They had three floors dedicated to treating the complications of diabetes. One was for dialysis, one was for recovering amputees, and one was for heart surgery patients. The article said that the hospital had just closed their diabetic education clinic because it was not profitable. They only got maybe a few hundred dollars from insurance companies to pay to educate one diabetic. But an amputation could bring in tens of thousands of dollars. Dialysis ran several thousand dollars per month until the patient died. And of course heart surgery was where the real money was reaching more than a hundred thousand dollars.

    1. Nate, I would love to get a title for that series, or a date range. Sounds like fascinating stuff.

      Yes, the link between obesity, health, and socioeconomic status has been written about for a number of years. One of the first scientific articles to study “obesity as a social phenomenon” was published in 1965.

      Type 2 diabetes is an excellent disease as far as opportunities for building clinics, employing providers, and selling stuff. Not so good for the people who actually have to have it. Currently, however, diabetes education is big business. It used to make me insane that virtually ALL of the education materials that RDs had to give to patients in the hospital where I did my internship came from insulin manufacturers. I used to point this out to the patients I was educating: “Here’s a helpful booklet made by insulin manufacturers. If you follow their advice closely, you can rest assured that you will need ever-increasing amounts of their product.” They would be puzzled for about a half a second. Then they would get it. I was happy to see that people can be smarter than we give them credit for, but sad that I didn’t have something more straightforwardly useful to give them.

      1. Hi, well, my memory of the articles is stuck on a couple of the pictures and the actual pages that were nearly completely full of that one story. So, my best guess is between 1995 and 2000. Though it could be plus or minus 5 years and sadly possibly even more. I would also guess that it had the word diabetes in the title. With 65 years of memories, my mind’s filing cabinets are getting a little cluttered.

        Interesting that now diabetes education is big business. I’ve been to a couple of diabetes support groups and, as I think about them, yes there were spaces for regular meetings and several other offices around that space. It did not occur to me how that space was being used or how it became profitable to maintain it. If you would have asked me earlier, I would have said the hospitals were simply trying to provide the best care for their patients. That may not have been untrue but obviously there is more to the story. People, including scientists, are so complicated.

        I have to go to the library today so I’ll take a moment and ask them about locating that article. Type to you later.

          1. Well, my guess was a bit off. It was January of 2006 and it was the Beth Israel Hospital and it was a Chinese person. Anyway I got the jest of the articles right, if not the details. Here they are:

            1. ‘Diabetes and Its Awful Toll Quietly Emerge as a Crisis’ by N.R. Kleinfield, 1/9/06
            2. ‘Living at the Epicenter of Diabetes, Defiance and Despair’ by N.R. Kleinfield 1/10/06
            3. ‘Early Health Problems Predict Later Eating Woes’ by Nicholas Bakala 1/10/06
            4. ‘Unlocking the Diabetes-Heart Disease Connection’ by Cathryn M Delude 1/10/06
            5. ‘In Treatment of Disease, Success Often Does Not Pay’ by Ian Urbina 1/11/06
            6. ‘East meets West, Adding Pounds and Peril’ by Marc Santra 1/12/06
            7. ‘On Not Knowing What Hurts You’ by Henry Fountain 1/15/06
            8. ‘In Newark, A Ward Boss with Influence to Spare’ by David Kocieniewski & John Sullivan 1/16/06
            9. ‘Gene Increases Diabetes Risk, Scientist Find’ by Nichols Wade 1/16/06

            I had not researched in the library for something for like 40 or 45 years. Guess what, they don’t have those little drawers with those 3×5 cards with all of the info. They use computers. Who knew?

            1. Wow! Thanks so much for all of this. The media tends to focus so much on obesity; I find many fewer articles on diabetes. These look like terrific finds.

              And, yes, as someone who was a student throughout the transition from the little drawers (I still remember the way they smelled) to the computer search, well, I’m still a little boggled.

  8. What I find intriguing is that the same phenomenon you are describing here (boiling it donw to rich = skinny and poor = fat) is developing in my country, too. And that country is Italy. I don’t have the stats, but I know that obesity is growing in Italy, and my perception is that we are one or two generation behind the USA in this processed food/avoid home cooking thing.

    Let me quickly elaborate. Fresh, raw food in Italy is pretty cheap, and we have the habit to cook at our homes. Plus, we have lots of quick recipes -the omnipresent pasta, for example, is healthy (especially if you do not use much oil) and you can cook it in literally 10 minutes, with practice. Only the youngest generations experience something as awful as “bring the kid to eat burgers at the fast food for her birthday” (I feel shivers while I write this). What strikes me in your post is how the typical low income person approaches the food at the supermarket. Yes, we do buy and eat (heavily) processed food in Italy, but for example, you want to eat the chicken, why go for the tenders? You can get chicken breasts and make your “panatura” yourself (a few minutes mixing eggs, flour etc.). This is my mental attitude, but I guess most of the Italian moms would think the same. Plus, we go for the olive oli. Extra virgin olive oil, glass bottle. This is a cultural thing. Even people outside the bubble avoid seed oil (unless they are *really* poor) in the plastic bottle. (For the same reason, if they are not alcoholics, they want to see a real cork on the wine bottle, wood or plastic, but the kind of cork you can’t get off without the proper tool.)

    Then, of course, even the proper home cooking can be deadly (including cooking pasta sauce frying butter AND olive oil, or eating a lot yummy cheese etc). I’m not saying the culinary tradition in Italy is a healthy one. But this processed vs. raw food is definitively a thing. And we’re shifting towards the processed one.

    1. I visited Italy a few years ago with my family. It’s a breathtakingly beautiful country, so I don’t want to start any international food wars with someone from such a wonderful place in the world. But: unless you are making it from scratch at home (and even then, you have to use “processed” flour), pasta is a “processed” food. The distinctions between what is “okay” processed food and what isn’t shifts around depending on historical, cultural, and personal context. We have yet to develop a good way to think about this; most of our “commonsense” notions about this aren’t, necessarily. Nutrition. It’s complicated. 🙂

        1. Well, not just yours 🙂 I think a lot of us (me included) tend to toss around that word without really thinking about the extent to which processing is a good thing–important for food safety, preservation, and convenience. So that just means we could stand to think about it more.

  9. This whole post purports to explain why rich people are lean and poor people are fat. The reasons given are sensible and compelling, but … well … the facts don’t support the basic premise.

    Look at the statistics, and you’ll see that only rich, white women are leaner than their poor counterparts (statistically significant difference). Look at overweight + obesity, and the trends are even weaker.

    Call me cynical, but it seems a whole lot more likely to me that skinny girls become skinny, rich women, and that fat girls become fat, poor women. Weight discrimination, thin privilege, and all that (including the chances of marrying up). The thin = beautiful ideal being stronger for white women, the trend is stronger in white women.

    1. You’ve got some good points (the last paragraph is especially trenchant), but we’re not just talking about obesity (as Jennifer mentioned in the first paragraph). Although the trends for women with regard to obesity and SES are clear in female populations, they are messier in male populations. This is true. However, the trend in diabetes is unmistakable in both; if you have a higher income, you are less likely to have diabetes. I’ve got some commentary on Jennifer’s post coming up, and I’ll go into more detail then.

    2. You do make some interesting points. When I look at the CDC data, I notice that the upper tier is only 350% of the poverty level. This is really not the bubble — the neighborhoods I am talking about would probably average 500%+ of poverty level median incomes. And, of course the private school thing would skew that even higher. Perhaps you have access to data that is parsed more finely. If you do, it would be interesting to look at what it shows at the upper end of the income range.

      I did find one paper, (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2709073/) where the authors looked at King county, Seattle, and concluded, “property values were the strongest predictor of the area-based smoothed obesity prevalence.” The figures were pretty interesting… maybe I can ask Adele to post one. Unfortunately, the obesity data from the CDC seems to go to the county level, but not down to the zip code. Perhaps there is a way to look at this type of zip code analysis on a broader scale — California seems to have a public site with some obesity and diabetes data that drills down to the zip code. (http://askchisne.ucla.edu) Unfortunately, that is outside of my skill set.

      One of the reasons I chose to write about this touchy subject is that I suspect that many of the policy makers (like our lawmakers and those scientists and medical professionals on the DGAC) might live in their own bubble, where they see a lot of people having success with the status quo. What they might not always see is the privilege at work behind that success, as, over time, I think many of us take our particular reality for granted. Could those pockets of affluence actually be populated by naturally skinny girls who married up? Perhaps, but those women do seem to spend an awful lot of time exercising and cooking compared to the rest of the population. Either way, whether they are naturally skinny or buying their way to thin, I hope our policy makers will eventually look around and figure out that the current DGAs aren’t working for most and come up with something different recommendations (or more options).

      1. I feel you’re not addressing the crux of my comment. You say that rich people adopt behavior that make them lean, but those behaviors are expensive. I say the data does not support your hypothesis. Have a look at the stats (really, you should have done that before!):


        If money allows white women to control their weight better, then why does it not work in black and latino women? Why does ot not work in white and latino men? And why does it do the opposite in black men (obesity is more prevalent in rich black men than in poor black men [statistically significant trend])?

        Furthermoe, most lean people I know are some variety of lean no matter what they do. Their behaviors will influence whether they are skinny, slim, or normal weight. Yet many of them tend to take credit for their leanness, thinking that they earned it with their valiant choices. In other words, they were born on the finish line and they think they won the race. With that in mind, your article does come across as patronizing.

        Lastly, I don’t know where you live exactly and what the true statistics are in your “bubble” but I would be flabbergasted if obesity were below 5% (the link you posted to Seattle data hints that it is indeed highly unlikely). Add overweight stats to the obesity stats, and it is almost certain that at least 20% of people in your neighborhood are fat. That’s one in five. Yet you say that you don’t see any. Well, fat people often do feel invisible, and they may avoid crowded places where they will be rejected, like you son’s football game (assuming that their children would even be accepted in his school, despite having fat parents).

        All in all, your thesis doesn’t hold up.

        1. Well, I was going to address this later, but I might has well do it now: race. Race and ethnicity are likely to affect, biologically and culturally, issues related to weight. But this seems to be play out differently in men and women. From the link that you supply, in every category of race and ethnicity, “Higher income women are less likely to be obese than low income women.” Although as you noted before, the trends are only statistically significant for white women, the pattern is apparent in each category of race and ethnicity (I’m not interested in getting into a discussion of significance vs. trends vs. “real life” here). So it does appear from this data that–at least in the upper income categories (and that’s what we’re talking about here)–money does, to some extent, help black and Latino women control their weight better than their middle- or low-income counterparts. In fact the differences between the percent of obesity in wealthy Mexican-American and their middle-income counterparts is nearly identical to that of non-Hispanic white women, although there is not a similar increase in obesity between middle- and low-income Mexican-American women as there for non-Hispanic white women (which is why the “trend” doesn’t hold here). For black women, I suspect that the issues are more complicated still, beginning with Daisy Zamora’s work.

          This overall pattern does not hold true for black and Latino men, and even non-Hispanic white men of middle income are more likely to be obese than their lower-income counterparts. There are likely to be a number of things at play, but I’ll quote from Harvey Levenstein, who addresses issues of weight and class in his “social history of eating in modern America:” 1) Men–in general–are “concerned” about weight, but less prepared to make the sacrifices that it takes to stay thin (perhaps the incentive to make these sacrifices increases as the income level approaches 1%er status?), 2) Groups who have only recently come to share in “historic markers of material success [like] the thick beef steak” still regard them as part of “the good life,” and (one that Levenstein doesn’t mention, but should), 3) those at lower rungs of the income ladder are much more likely to make a living through manual labor, which can reduce opportunities for excess calories to accumulate. (And it may be that for the last two items, these factors impact women the same way as well).

          I found the Drewnoswki et al. article to provide some support for what Jennifer has observed in her own “bubble,” specifically this, that “geographic disparities were much higher than those traditionally ascribed to race or ethnicity.” And there’s this idea of “social class” not captured in education and income data: “Traditionally, race/ethnicity as well as education and incomes have been the focus of health disparities research (Isaacs & Schroeder, 2004). Given recent concerns that individual education and incomes may not adequately reflect social class (Marmot, 2000), there is a growing emphasis on the roles of occupation, social capital, and social context, all difficult parameters to capture in epidemiologic studies.”

          And I think your suggestion that people who are overweight or obese and live in a place where the social norms would make a fat person “feel invisible” enough to avoid public spaces would support the idea that “failing” at being thin in “the bubble” would carry a higher degree of social disapproval there than elsewhere.

        2. Again, you make many good points. I completely agree that just as there are some naturally skinny people, there are people who are going to be overweight or obese regardless of what they do. I should have said that. I am with you. I also agree that some ‘normal’ people are really just going from the heavy side of normal to the lighter side of it, yet attributing their normal weight to their efforts rather than genetics. However, to be fair, how are they to know that? I personally gain about a pound a day when I am on vacation and eating less carefully… would that slow down – yes. Would it stop before I became overweight or obese? I don’t know. My only sibling is obese, so I’m thinking it is very possible that that is where I would end up. Maybe affluent people’s personal experiences, rather than patronizing attitude, inform their ideas about how much of a role diet and exercise play. I am very grateful and aware that my genetics are helping me out by making lean possible, but I think my low-carb eating pattern is key to making it happen.

          I agree that the women are leaner. I see them more and they probably skew my vision towards seeing less obesity than there is. Also, men often conceal weight more easily due to looser clothes and larger frames so perhaps I underestimate what is going on with the dads. I won’t speak to race, as Adele addressed it nicely. I can confirm your suspicion that I am talking about a very white community.

          Where we disagree is about whether money even matters. The link you sent does actually confirm it matters for white women. But, again, it has no information about the kind of affluence I am discussing. Household income north of $77K for a family of four is far too low to speak to this issue. When I play with the CA site, I see groups of affluent, white zip codes with obesity rates as low as 12%, and I see mostly white zip codes with modest incomes and rates over 30%. I think that is a huge difference and that its cause should be explored.

          I intentionally avoided estimating how much obesity and overweight I see in the stands — I am not a clinician and I really would have no way of knowing. I also have no interest in creating that sort of inventory of my friends and acquaintances. I am speaking to the overall effect, which is marked. Is it possible that I am missing some people in my crowd? Sure. I can see that I might be less likely to label a friend as obese, and more likely to be tougher with the strangers on the other side of the field. But if your guesses are correct — let’s go even higher on obesity given the CA data — 12% obesity and 20% overweight — that is extremely different than our national averages. We would expect to see only 40% ‘normal-to skinny’ in an all-white crowd. What explains the fact that we see 68%?

          And please rest assured that my kids’ school lets in any kid who can do the work and can afford tuition. It is not full and budgets are tight. So even if there was something evil afoot in the admissions office, economic realities would overcome it.

          1. The point that you make about you and your obese sister is a good one. It’s easy to tell slim people that they’re lucky, but I don’t think the luck lasts into middle age. I used to work in an office with two lovely but very obese ladies. At least once a day, they’d tell me how lucky I was to be slim, as they offered me another biscuit (sorry, cookie) and grazed endlessly on junk. I think my luck had quite a bit to do with avoiding the stuff they were eating and exercising might have helped a little. They weren’t helped by the fact that they were conscious of fat but careless of sugar.

            Take a look at the super-fit skinny athletes you knew at school and what they’re like at 40 or 50. For some the luck ran out. I do think we get dealt different hands, but for most of us what we do afterwards matters most.

            1. Thanks, Stephen. He’s a brother, actually! You are right on about the obesity creep that occurs as we age. Just as our eyesight gets worse and worse, our body’s ability to tolerate bad food seems to decline, too. That is a cruel bait and switch for kids who start out lucky but don’t stay that way. Some of this may be declining activity levels as life responsibilities get in the way of sporting activities, but it happens to people who are even more active as adults, too. As Malholtra says, ‘You can’t outrun a bad diet.’

        3. I’m just getting to all these posts after reading the guest host’s piece about how money buys lean and health. Very thoughtful piece!

          I decided to reply to Valerie’s posts because hers was the most strident and, in my humble opinion, off-base. I did not feel she got the point of the trends that are now being documented–trends that show the relationship between income and health. Acknowledging there are disparities between income levels and health outcomes is a first step to seeing what can be done to change the paradigm for lower income families. (A LOT can be done.)

          Valerie asks, “If money allows white women to control their weight better, then why does it not work in black and latino women?”

          I would proffer the idea that black and latino women who are in higher income brackets (but still not controlling their weight) have probably climbed the ladder more recently than their higher-income white counterparts, which would mean that they may still be living in two worlds, with the world they left still influencing diet and habits.

          1. I think your comment is very perceptive, that black and latino women may be “living in two worlds”–another situation which may add stress to an already stressful life. It may be that these are women (or family units) who make into higher income brackets working multiple jobs (due to institutionalized limits on income for reasons of race or gender or both). You’ve added an interesting insight to a complex picture.

          2. Hi S. Curtis,

            I didn’t talk about health at all. I was addressing overweight and obesity. Though they are probably related to health, I feel overweight and obesity are a whole lot more about appearances (especially in their relation to socio-economic status).

            I truly don’t know why rich people tend to live longer than poor people. My hunch — and it is just a hunch — would be that it is about stress (i.e. financial insecurity would take its toll). I would be interested to see what happens to that trend in countries where health care costs are partially or completely covered by the government. I’m more sceptical than you about changing the world though: I would also ask to see hard data on intervention studies before concluding that “A LOT” can be done to bridge the health gap between socio-economic classes.

            I guess your explanation about black and latino women could be part of the answer. But then, you leave out all the other discrepancies. Why does wealth not buy thinness in white men? Why does wealth make black men fatter instead of leaner? The data had 6 subsets. The rich = lean trend is apparent only in 1 on those subsets (white women), it goes backwards in 1 subset (black men) and it is insignificant in the remaining 4. Seems to me that money doesn’t buy leanness after all.

            1. Hi again, Valerie, and hi S. Curtis.

              I am glad we are having this exchange, because it makes me realize that the CDC data on income levels is divided so broadly, it masks a trend that I see every day… and perhaps S. Curtis, you see it too. I agree that the paper Valerie sites backs up what she contends about the overall trends, but again, lumping all people in households of four that earn more than $77,000 into one tranche obfuscates what is going on at the upper end of that traunche. With black and latino Americans, relatively more are close to the $77,000, and relatively fewer are in the top 5% of earners (which is the bubble I described). This means fewer individuals from these ethnic groups are benefiting from the privilege I describe. Last year, the Huffington Post published an article (http://www.huffingtonpost.com/antonio-moore/americas-financial-divide_b_7013330.html) about the racial divide in the top 1%. Although this is a narrower segment than the top 5%, it illustrates my point. White households (96.1%) are overrepresented and black (1.4%) and latino (0.9%) households are underrepresented.

              It is unfortunate that the CDC did not decide to divide its obesity and overweight data into more traunches. Maybe it does not want to reveal the inconvenient truth I wrote about in this post. In my experiences with upscale crowds — be it in my neighborhood, on vacation, or at fancy restaurants or shops — the men (and the African American men) are relatively leaner than what I might see in a mainstream crowd. It is definitely most pronounced with white women, but I see it with both men and women, black and white. Living where I live, I can’t really speak to the latino population.

  10. As a dog returns to its vomit, so those fools repeat their folly. But seriously – the use-by date is 2020 now????

    “In addition to helping reduce chronic disease risk, the shifts in eating patterns described in this chapter can help individuals meet nutrient needs. This is especially important for nutrients that are currently underconsumed. Although the majority of Americans consume sufficient amounts of most nutrients, some nutrients are consumed by many individuals in amounts below the Estimated Average Requirement or Adequate Intake levels. These include potassium, dietary fiber, choline, magnesium, calcium, and vitamins A, D, E, and C. Iron also is underconsumed by adolescent girls and women ages 19 to 50 years. Low intakes for most of these nutrients occur within the context of unhealthy overall eating patterns, due to low intakes of the food groups—vegetables, fruits, whole grains, and dairy—that contain these nutrients. Shifts to increase the intake of these food groups can move intakes of these underconsumed nutrients closer to recommendations.”
    Ahem DGAC, I think you will find the missing iron, choline, and vitamins A and D in a “food group” or two that you have not mentioned here and are telling Americans to cut back on. To wit, meat, organ meat, eggs, and dairy fat.

    Personne n’est corrigé; personne n’a su ni rien oublier ni rien appendre. “Nobody has been corrected; no one has known to forget, nor yet to learn anything.” – Charles Louis Etienne, Chevalier de Panat,

    Beautiful guest post explanatory of the “inequality paradox”. Thank you.

    1. Very eloquently put.

      Even knowing what I do, I am still impressed with arrogance of this sort of thing. As if we are all idiots and would never second-guess or fact check their assertions.

      I agree, Jennifer did a great job with a sensitive topic.

  11. I think your points are valid, and also why epidemiological studies are really studying people (including their income), and not dietary effects, per se. At my house, we eat locally-grown pork and beef (we’ve taken to buying parts of or whole animals), organic milk, butter from grass-fed cows, many organic foods, fancy cheeses, etc.. (Though milk from grass-fed cows remains too expensive even for us.) We’re also making our own yoghurt and periodically bread from einkorn wheat (an “ancient” wheat), and will soon be making our own fermented foods. We also have the ability to eat mainly food we cook ourselves. We eat very few prepared foods and basically nothing in cans.

    Compare that with what I used to eat when I was in college: brown rice, beans (mainly canned but I also cooked them myself), pasta (though at the time I thought these were the epitome of “healthy”). It’s much cheaper to eat like that, and you can feed many more people too. Carbs are cheap, relatively speaking.

    1. While I was at UNC-Chapel Hill, everyone in the nutrition epi division got in a huff when a visiting speaker from Yale kept referring to nutrition epidemiology as a “social science” (which may possibly a bit of an insult to the other social sciences). The nutrition epidemiologists I know never interact with actual people; they interact with databases–so I get your point, but I’m not even sure they are studying people as much as they are studying numbers that may or may not actually represent something about people.

      And yes, carbs are cheap. My first foray into vegetarianism was for economic reasons.

      1. That is true. With an epi study, you can read it in any number of ways, most or all of which will be wrong.

        Still, when you look at “processed meats cause cancer” epi studies, for instance, these are really looking at people — those people eating the notoriously-“bad”-for-you processed meats are those flaunting any guidance or too poor to be able to afford better. When I have a lunch of bologna and liverwurst at work, people are shocked. “Isn’t that — gasp! — processed meat? Aren’t you worried about cancer/saturated fat?” I neglect to point out that I’m also putting a ton of fatty cheese and home-made chipotle mayo on the meat, too, as that could cause their heads to explode. Now, I’m a rebel who thinks everything about nutrition is either wrong or unsupported by scientific evidence, so I would throw off these types of surveys and their corresponding epi studies.

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