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The Mental Health Million project queried over 220,000 people on well-being — and the results are worrying.
There’s little doubt that mental illness is a major cause of human suffering around the world. But it may be harder to address than other deep problems like disease or poverty, partly because mental well-being is so difficult to quantify.
That’s what the Mental Health Million project at Sapien Labs, a nonprofit founded in 2016 to study the human mind, is meant to address. The group last month released its second annual Mental State of the World report, surveying over 220,000 people in 34 countries with its Mental Health Quotient (MHQ) questionnaire.
The questionnaire came out of the group’s frustration at the lack of a single, comprehensive scoring tool that aimed to capture the full range of mental well-being across a population, not just in terms of illness or disorders, but on the positive end as well. After reviewing a number of existing clinical tools or questionnaires, they arrived at a list of 47 elements to use as questions in the MHQ scale, which could be filled out as an online questionnaire by respondents in about 15 minutes. The survey is freely available online to anyone who wants to take it, and participants in the study were actively recruited mainly via Facebook and Google ads. (The researchers note that this may not result in a population-representative sample, though the same methodology was used in all countries surveyed.)
These inputs are used to calculate an aggregate score between -100 and +200, with the full range divided into categories on a spectrum from “distressed” to “thriving.” The 47 total elements are also organized into five areas based on what aspect of well-being they focus on — mood and outlook, drive and motivation, social self, mind-body connection, and cognition — with separate scores for each. The MHQ has been validated and shown to give reliable results on retakes, and “negative” scores correlate strongly with qualifying for a DSM-5 diagnosis, and the results are also predictive of productivity.
The initial results of the survey aren’t reassuring.
One standout finding was a worrying decline in mental well-being in the 18-24 age bracket. That’s a surprise: Previous mental health surveys — albeit ones that were mostly US-only and employed different measurement tools — tended to show a U-shaped curve of well-being over the course of a lifetime, with the youngest and oldest groups faring best and a dip for the middle-aged.
While concerns about the state of youth mental health have been growing in the US — a new CDC survey found that more than four in 10 adolescents reported feeling “persistently sad or hopeless” — Tara Thiagarajan, the founder and chief scientist at Sapien Labs, told me, “it’s not an isolated issue of one country. It’s a global issue.”
This trend was already present before the Covid-19 pandemic but worsened significantly between 2019 and 2021, with the total percentage of people scoring in the “struggling” or “distressed” range doubling between 2019 and 2021, to 30 percent. Notably, the decline was correlated more closely with the stringency of lockdown measures rather than the direct damage from the pandemic.
The researchers considered various possible causes — income inequality, political instability, civil unrest — but none of these factors has been consistently worsening around the world.
One factor is truly universal: rising smartphone use and internet access. Despite longstanding concerns that smartphones and social media exposure harm mental health, especially for young people, existing studies have shown mixed results.
But the researchers behind the Mental Health Million report speculate that the key factor may not be the internet itself but what time spent on the internet replaces. Recent global statistics suggest that people with internet access spend on average seven to 10 hours per day online, which could crowd out in-person interaction that is key to building a strong social self.
Building social skills and relationships requires time and experience. But Thiagarajan believes the youngest generation has “arrived at age 18-24 and college with one-tenth of the expertise in solving social issues, living together, coexisting in productive ways without conflict. And I think a lot of the unrest and conflict may be quite related to that, because at age 18, now you have the same experience of interacting with people as a 7- or 8-year-old had in the past.”
If the existing decline in mental well-being among young people was related to internet use crowding out in-person social time, it follows that the isolation of lockdowns would have hit the 18-24 cohort especially hard. And previous studies show that lower mental well-being scores on the country level correlate with higher rates of suicide, sexual violence, and violent assault, especially for the 18-24 age bracket.
The Mental Health Million team hopes that the MHQ will provide a better understanding of this key issue. It’s admittedly imperfect — the questionnaire is only available online, in just four languages (English, Spanish, French, and Arabic), and would mostly have attracted participants who were in a position to see online ads. This population might be unrepresentative in a number of ways; for one, especially in poorer countries, internet users are likely to be the wealthiest and best-educated segment of the population, and differ from the average in other ways.
Even in countries with more ubiquitous internet access, young people who spend the most time on the internet and might thus be hit harder by the resulting negative well-being effects are likely overrepresented; conversely, for older people, the internet-savvy may be better connected and educated than the norm for that age group, which might contribute to the consistently high reported well-being in the 65-plus cohort. Cultural factors could also affect how people interpret survey questions, as well as how they relate to the concept of well-being and mental illness; this makes the patterns found on the country level with cultural indicators more fraught to analyze.
Countries and cultures seemed to affect mental well-being in other, unexpected ways. Counterintuitively, higher national GDP was correlated in the survey with lower self-reported well-being. The English-speaking countries — the US, UK, Ireland, Canada, Australia, and New Zealand; all developed, rich countries — had the worst average scores. “We were very surprised to see that,” says Thiagarajan.
The report also looked at cultural factors on the country level, employing indicators compiled by the Globe Project and by Geert Hofstede at Maastricht University. Of the factors examined, performance orientation, which measures the extent to which rewards and recognition are based on job performance, had the strongest negative correlation with average MHQ scores in a country — despite the fact that societies high on this dimension tend to be more economically successful, with higher levels of human development.
On the other hand, the factors of higher power distance (cultures that accept an unequal, hierarchical distribution of power), uncertainty avoidance (cultures that emphasize social norms and rules), and in-group or family collectivism (societies that express pride, loyalty, and cohesion within families) are all positively correlated with mental well-being. As the report puts it, “altogether these relationships paint a surprising but consistent picture: a culture where we are each for ourselves and judged and sorted by performance may be good for economic growth but damaging to our collective mental wellbeing.”
Mental Health Million acknowledges that their survey data and report are only a first step, and further research is needed. Their data is available to researchers on request, and about 20 organizations are already working with it in the hope of finding ways to improve worldwide mental well-being. According to Denver Brown, a psychology professor at the University of Texas studying the effects of physical activity and sleep on mental health, “these findings suggest that we can’t take a siloed approach to understanding mental well-being.”
In the past, the mental health effects of policies were hard to measure; when decisions were made about Covid-19 lockdowns, it was nearly impossible to take into account population well-being in the cost-benefit analysis. But the costs to mental well-being are real, and the Mental Health Million project shows that we can’t ignore it.
A version of this story was initially published in the Future Perfect newsletter. Sign up here to subscribe!
Customers are told they’re always right. Naturally, they’ve come to believe it.
Some of the angriest emails I’ve ever gotten from readers were over a story about credit card points.
The long and short of it is that the fancier the credit card rewards, the higher the swipe fees for merchants. Those merchants often pass along the costs of those swipe fees to all customers, whatever the payment mechanism. People who pay with rewards cards tend to be more well-off, financially, and their hotel points or flight miles are being, in part, subsidized by people paying in cash or debit who tend to be poorer. A 2010 paper found that households that use cash pay about $149 on average to households that use credit cards, and each of the credit card households gets $1,133 from cash users every year.
Essentially, credit card rewards have to come from somewhere, and they’re partly coming from people who aren’t reaping the benefits. Some readers were very angry to discover this information. “Maybe it’s time for people who don’t want to work to know how it feels to foot the bill for other people?” one person wrote to me, apparently equating having a rewards card with having a job. “If people want a better life I suggest education and getting a degree or a certificate in a trade,” wrote another person. “Boohoohoo. Who cares?” wrote another.
Some people seemed to feel that they had a serious right to accumulate credit card rewards, regardless of who or what those rewards were coming from. It’s a sentiment that bears out in the data: A 2019 LendingTree survey found that people were likelier to support a rate cap on credit cards if it reduced access for people with imperfect credit than they were if it meant it would significantly lower their rewards.
“What that essentially says is that more people [were] okay with fewer folks having access to credit than they were with having their own credit card rewards shrink,” explained Matt Schulz, chief credit analyst at LendingTree, in an email.
That consumers can be selfish isn’t a new phenomenon. Remember when everyone was hoarding toilet paper and masks at the start of the pandemic? But it is worth pausing and reflecting on how angry people feel when confronted with the idea.
“In our culture, we have excessively high expectations,” said Robin Kowalski, a psychology professor at Clemson University who studies complaining. Not just high expectations, but specific ones, about how the economy should run and what we should get out of it. We want things to be cheap, we want things to be fast, we want things to be efficient. For decades, American customers have been told they’re always right. Naturally, they’ve come to believe it.
People aren’t accustomed to having to really think about the trade-offs they make for the economy to run how it does, and when they do have to think about it, they don’t like it. Consumer-centric culture has made it easier for us to be destructive in ways big and small — to workers, to the environment, and to each other. Corporations have manufactured our high expectations, and it’s hard to reverse course.
“We expect everything to work just like clockwork,” Kowalski explains. “Heaven forbid the internet goes out or we get stuck in a traffic jam and can’t go as fast as we want to, and that’s immediately going to trigger dissatisfaction.”
Credit card rewards are nice for those who have them. They’re also not special gifts from the sky you’re entitled to because you’re modestly decent with personal finance or follow the Points Guy.
Consumer culture hasn’t always been this way, with expectations as high as they are, but we’ve gotten here over about the last century and a half. As Amanda Mull outlined last year in the Atlantic, merchants drew in buyers and trained them in a certain way — to believe that they’re guests, to get reassurance, to be told that they’re always right. Tipping culture emerged, tying a server’s pay to the whims of a consumer instead of a living wage. People’s identities became increasingly intertwined with consumerism and buying, with people comparing themselves to peers and consuming more in order to keep up. Mass manufacturing and mail-order delivery and merchandising and transportation have made it easier for people to get more and more stuff.
As companies have competed for our business, and technology has made the consumer experience feel even more efficient, expectations have risen. Customers are constantly updating their expectations based on prior experiences, advertising, competition, or the economy in general, explained Jihoon Cho, an assistant professor of marketing at Kansas State University’s college of business administration. And how they evaluate a service is whether it’s better or worse than expected rather than the objective measure of the actual service.
“The way we evaluate things is a function of expectations,” said Deborah Small, a marketing professor of psychology at Wharton. “If we’re used to a level of customer service, which Americans are, and then things change, like prices go up or things slow down, the violation of that expectation is what causes disappointment, anger, all of these sorts of things.”
Thirty years ago, people were generally fine with whatever they ordered off of the television arriving in five to seven business days, because it was the status quo. Now, thanks to Amazon, even two days can feel like an eternity.
David Mick, a professor of commerce at the University of Virginia, describes the situation as the “er” phenomenon, where people are led to believe that there is always something better ahead. “If you think about packaging or advertising, products across the spectrum are constantly positioning themselves as softer, sweeter, easier, smoother, quieter, longer-lasting, or just the big word, better,” he said. “We’re always being set up that whatever we’re looking at or considering to buy is better.”
Once expectations rise, consumers have a hard time going back. We’re averse to loss.
We’re seeing this clearly during the pandemic. Supply chain woes, staffing shortages, and other pandemic- induced uncertainties have translated to all sorts of shortcomings when it comes to what consumers expect, and there are all sorts of examples of people reacting terribly in turn. Passengers are attacking flight attendants on airlines. Customers are throwing fits in restaurants and grocery stores and retailers. They’re mad about wait times and inflation and thinly stretched staff. They’re also mad they’re not in the right when they refuse to wear a mask or show a vaccine card or, simply, wait.
Workers, in turn, are suffering. According to a June 2021 survey from Snagajob and Black Box Intelligence, 62 percent of restaurant workers report experiencing emotional abuse and disrespect from customers. The Association of Flight Attendants said in July 2021 that 85 percent of flight attendants dealt with unruly passengers in the first part of 2021, and 17 percent had experienced a physical incident. Consumers have been told they’re always right for decades, and for some, when that’s not the case, their reactions are extreme.
“Other countries have a more balanced view on ‘the customer is always right,’ and that’s somewhere that we can dig in as a society,” said Melissa Swift, US transformation leader at Mercer, a work consultancy firm. “Why do we believe that? That doesn’t have to be a baseline assumption.”
In a world where the consumer wins, there are often losers, whether that be workers, the environment, or the other consumers they’re competing with to get a piece of some limited socioeconomic pie. Inequality drives all sorts of anxieties and a class of what Richard Reeves, author of Dream Hoarders, describes as “opportunity hoarding” among the upper-middle class to try to maintain their place in society and keep others down.
The design of our consumer economy means we’ve made a collective set of moral and ethical calculations that some trade-offs are worth it. It’s a choice that servers in the United States are still paid a wage of $2.13 an hour and left to hope that generous consumers — who enjoy lower prices for their meals — tip them. It’s a choice that the gig economy of companies like Uber and DoorDash provide people with low-priced convenience without thinking too hard about the economic and personal consequences for workers. It’s true that Amazon and Walmart keep prices low — including for low-income consumers. It’s also true that the way they do it is by paying its employees very little and squeezing every ounce of work out of them that they can.
“For the past few decades, we basically built large sectors of the economy around cheap and easily available pools of labor, and we organized parts of our legal system to ensure companies had access to large pools of low-wage labor,” said Brishen Rogers, a Georgetown law professor focused on labor.
Part of what’s causing consumers such frustration right now is that cheap pools of labor are not so easily available. There are worker shortages across the economy, and the labor market is so tight that workers are able to change jobs quite easily — and say no to some of the most grueling jobs altogether.
There’s a limit to how “customer-centric” businesses can be. “You can start to do things to be so overly focused on your customer that you cause systemic breakdowns,” Swift, from Mercer, said. There are some jobs that have become so intensified that basically there’s no amount of money that makes the work worth it for some workers. It’s no longer a question of how much any business or customer can pay. Some people just don’t want to be teachers or child care workers or work in hospitality or food service — the demands of the job, including from customers (or, in the case of teachers, from parents) are just too much.
When Walmart workers quit, they often make the same joke: “I promoted myself to customer.”
It’s not super fun to be a consumer right now. Prices are rising, plenty of products take a long time to get or are unavailable, and many businesses are really short-staffed. Corporations are asking for patience from frustrated consumers as they try to make up for lost ground, but it’s important to note that corporations have a big role in how consumerism got here in the first place.
Susan Strasser, a historian of American consumer culture, stressed that consumer expectations in the US are a corporate creation. She pointed to the example of the mail-order business in the late 19th and early 20th century, brought about by companies such as Sears and Montgomery Ward. Previously, most people relied a lot on things that were locally produced, often by people they knew. When they were able to order by mail from catalogs sent to their homes, the whole system changed. “What it meant was everything American manufacturing was producing was available to people,” she said. “That kind of consumption, that kind of distribution, that kind of merchandising coincided with an avalanche of stuff.”
Yesterday’s Sears is today’s Amazon — you can get anything and you can get it fast, and you often don’t see the inner workings behind making what you’re getting possible. “As automated as it may be at Amazon, and we know it’s highly automated by the way that we can just click and it comes, there are people,” Strasser said.
Through advertising, marketing, merchandising, and other practices, corporations are ultimately the ones managing expectations. On credit card rewards, for example, credit card companies spent years competing with each other to make rewards bigger and better. It’s a good deal for the consumers who reap those rewards, but it’s making things harder for those who don’t.
Still, in the current moment, consumers are being met with a reality that for years a lot of people could conveniently ignore. “We have become an entitled society,” said Mark Cohen, director of retail studies at Columbia Business School. “We have been blessed, up until the last two and a half years, with relatively little, if any, inflation, in fact, deflation in many categories. We’ve been blessed, for those involved, with very low interest rates and pretty much open-ended availability of money. People have been able to buy houses and cars and use their credit cards.”
The distorted reality we’ve been living in over the past two years, he said, has made everybody “grumpy,” and that often boils over in our consumer experiences and in retail. “The supermarket, the gas station, the department store, the mall, it’s kind of where it all comes to a head.”
Right now, consumers are having to lower some of their expectations by force — and many, understandably, don’t like it. But it may also be a moment to reflect on how we got here and whether we want to stay here. Consumerism means we often make things worse for each other, whether it be hoarding toilet paper, yelling at a service worker, or replacing an item that’s perfectly fine.
“It really comes down to the trade-offs and what, as a society, we value,” Small said. All else equal, efficiency is good, quality is good, lower prices are good. But all else isn’t equal. “Nobody argues that they’re not valuable, but it comes down to how we as a society think about trade- offs.”
Companies and capitalism and society have trained us to be bad consumers. It’s behavior that can be untrained, too.
We live in a world that’s constantly trying to sucker us and trick us, where we’re always surrounded by scams big and small. It can feel impossible to navigate. Every two weeks, join Emily Stewart to look at all the little ways our economic systems control and manipulate the average person. Welcome to The Big Squeeze.
Have ideas for a future column? Email emily.stewart@vox.com.
Noom is a diet app in an anti-diet moment.
Imagine that you could lose weight without going on a diet.
Imagine that you could repair your broken relationship with food, with hunger, with your own skin, and in the process shed those 10 pounds you’ve been wanting to lose. Imagine that you could simply learn how to get in touch with your body — thoughtfully, mindfully — and teach yourself not to crave foods that don’t nourish you. Imagine that you could transcend America’s toxic diet culture, and at the same time, you could also be really, really skinny.
That’s the dream that Noom, a buzzy weight loss app targeted to young people, has been selling for years. “With Noom, every day is ‘No Diet Day,’” it declared on Instagram last May. “And yes, we also help people lose weight,” it added in the caption. Noom’s messaging insists that it teaches users healthy, sustainable habits that leave them feeling happy and satisfied as the pounds melt away.
The no-diet diet angle paid off. In February, the Wall Street Journal reported that Noom was valued at $4.2 billion in May 2021, and late last year it expected its 2021 revenue to total more than $600 million. It was even circling the possibility of an initial public offering for early 2022, with a prospective valuation of $10 billion.
But the Wall Street Journal didn’t think that IPO was going to happen anytime soon. “Noom’s key differentiator — applying psychology to achieve long-term weight loss — has recently backfired,” it explained. Critics say that Noom is just another diet app at best, and a deceptive gateway to disordered eating at worst.
“The idea that there could be a way to lose weight without having all of the psychological and emotional hang-ups around food and diet culture is super appealing,” says Meredith Dietz, the reporter behind the recent Lifehacker article headlined “Fuck Noom.” “But I don’t think Noom actually delivers.”
Virginia Sole-Smith, the journalist behind the fat activist newsletter Burnt Toast and a high-profile critique of Noom in Bustle last October, agrees.
In an interview, Sole- Smith said she was drawn to reporting on Noom in part because of the client base that its “not like regular diets” ad campaign was drawing on. “I was hearing from a lot of people who were doing it who didn’t think of themselves as dieters and wouldn’t want to be doing a diet,” Sole-Smith says. “They were like, ‘Well, it’s helping me rethink some of my habits and unpack some of my issues with food.’ And then a few months later, I would hear from them again being like, ‘Actually, it’s ruining my life.’”
The fight between Noom and its critics is part of a larger cultural war that has begun to play out over the past 10 years over how we should think about food, weight, bodies, and health.
In one corner is the traditional diet culture most American women grew up in, which holds that weight is a crucial indicator of health. Under this system, it’s an article of faith that if you simply exercise a little willpower and expend more calories than you take in, you will lose weight. It is also an article of faith that it’s important for your overall wellness and your personal happiness that you be thin at all costs.
In the other corner are the rising anti-diet and Health at Every Size movements. Citing a mounting pile of research, these groups hold that the correlations between weight and health are not nearly as straightforward as diet culture would have you think. What’s more, they add, most diets do not result in long-term weight loss and can even damage your metabolism in the long run.
“There is no other product that could have a 5 percent efficacy rate and be peddled as hard as diets are peddled,” says Sonya Renée Taylor, founder of the digital media and education company The Body Is Not an Apology, citing a widely quoted study from 1959. (While the 95 percent number has been called into question, other studies do consistently show that the vast majority of diets fail.) “And yet corporations still sell diets and sell the idea of a smaller body as a more valuable body, as an inherently healthier body, as a better body.”
Noom appears to be trying to split the difference between traditional diet culture and the rising anti-diet movement. It positions itself as a program that teaches users to lose weight the smart, healthy way, following the tenets of the body positivity movement while still helping users make their bodies healthier.
Its critics say that beneath the buzzy wellness vocabulary and millennial pink branding, Noom is just another diet app. What makes it different from Weight Watchers, Jenny Craig, and their ilk is that Noom is all dressed up in the rhetoric that activists have been using for decades to try to take down diet apps once and for all.
While Noom celebrates No Diet Day on Instagram, in practice, it works like a classic low-calorie diet. After registering, users are prompted to set a goal weight and to decide how quickly they want to lose weight. Noom will then generate a daily calorie budget that users are expected to follow, and it instructs users to log their food every day to make sure they’re staying on track.
While a stated part of the Noom philosophy is that no foods are off-limits, it does give users a stoplight system to classify their foods. Green foods may be eaten in large quantities, yellow foods are to be eaten in moderation, and red foods are to be limited. Because Noom’s system is based around the idea of caloric density, red foods reportedly include not only classic diet villains like desserts and potato chips and red meat, but also wellness favorites like nut butter and full- fat dairy. Green foods are those that contain a lot of water, like fruits and vegetables. Yellow foods include seitan, lentils, and avocado. (Noom doesn’t make the full lists of color-coded food available publicly, but other sources have compiled more comprehensive lists.)
In addition to the calorie budget and the stoplight system, users get a Noom health coach, a peer support group, and daily lessons on the psychology of eating. The whole package costs $199 for an annual subscription, or $60 by the month.
Some users say Noom is a great experience. Emily Gonzales, a 35-year-old labor and delivery nurse based out of LA, was on Noom from May 2019 to August 2020. She says she lost 190 pounds and succeeded in alleviating her Type 2 diabetes. (Two studies suggest that a very low- calorie diet can improve diabetes control and perhaps reverse Type 2 diabetes in people with obesity, although symptoms may eventually return — and reversal may not be possible for everyone with Type 2 diabetes. Per the CDC, a healthy rate of weight loss is one to two pounds per week.)
“I’ve tried everything, on and off, my whole life,” Gonzales said over Zoom. “I’ve done Nutrisystem. I’ve done Medifast, which is like five shakes a day and one real meal. I tried low carb. I tried starving myself.”
Gonzales says she always lost weight on the diets she tried before, but as soon as they were over she would go back to her normal eating habits and gain the weight right back. She could never figure out why certain foods were supposed to be good and other foods were supposed to be bad on any particular diet, so she could never stick with the habits she made there.
Noom, she says, is different: “They teach you the why.” She knows which foods are dense in calories and which are high in water, and she says that eating less calorie-dense foods keeps her fuller for longer.
“I’m never hungry,” she says. “I eat tons of veggies, tons of fruit.” Gonzales is currently on a diet of 1,400 to 1,800 calories a day and plans to continue on it, although she no longer tracks her calories daily. (Health professionals recommend women eat around 2,000 calories per day, although this number is highly variable depending on levels of physical activity, metabolism, age, height, and more.)
Other Noomers didn’t have such a good time. Sara Davis, a 40-year-old marketing and communications writer in Philadelphia, says she turned to Noom in 2018 for help managing her chronic illness.
“I had read a lot of fat acceptance blogs, so I knew that diets didn’t work,” Davis says. She has Hashimoto’s thyroiditis, an autoimmune disorder that can include weight gain among its symptoms, and she had been gaining weight steadily for years.
“It obviously negatively impacted my life in many ways,” Davis says. “I experienced body dysmorphia. I had to buy new clothes every year. I was seeking out ways to manage my weight that didn’t seem to be diets.”
For a while, Davis went to a nutritionist, who taught her to keep a food journal and watch her calories in and her calories out. Then she switched jobs and found that her new insurance wouldn’t cover the treatment. Noom presented itself as an affordable solution: a way to lose weight that wasn’t really a diet.
Once she signed up for a free two-week Noom trial, Davis found herself disappointed. She was already tracking her daily exercise and food intake in a series of detailed charts and graphs. She already had a basic understanding of nutrition, so Noom’s daily tips and calorie-tracking systems weren’t doing much for her. “It talked to me like I was very stupid,” she says.
The one big change Noom did offer Davis was that it cut her daily calories, by a lot. She was already eating a fairly small daily allowance of 1,500 calories, but Noom brought her down to a 1,200-calorie diet. That’s what nutritionists consider the bare minimum required for most women to sustain daily living. Some of them call it a starvation diet. (Noom announced last November that it would no longer recommend 1,200-calorie diets and raised the level by 10 percent, setting a new minimum recommendation of 1,320 calories for women.)
“As a person with Hashimoto’s thyroiditis, I always struggle with energy and mood and just being tired all the time,” Davis says. “But on 1,200 calories I was very tired. I could not think. Very achy. And then it made me mean. I was so irritable. I was snapping at people. I was impatient. I had kept having to apologize for things that I said. I was not myself during that period.”
Davis decided to cancel her Noom membership before the free trial was over. She found, though, that Noom had gotten into her head: She kept counting calories and she kept trying to restrict them as much as possible.
After a few months, she decided she wanted more structure in her weight loss efforts. She applied to enter a weight loss study at the university where she worked.
There was just one problem. To enter the study, you had to go through a psychological screening first. Once Davis had been screened, she was told she couldn’t join the study. Instead, she was given a reference to a disordered eating clinic.
“So that was for me a wake-up call,” Davis says. “I was doing things that are considered normal by some — by Noom, by the general culture. But they’re actually not. They’re maladaptive behaviors. They’re disordered behaviors.”
Now every time Davis sees a Noom ad, she says, she reports them as a scam.
Davis and Gonzales had extreme experiences with Noom. A lot of people go through Noom without either curing their chronic illness or getting a diagnosis of disordered eating. Instead, many people have the same experience almost everyone has on a diet: They lose some weight, stop the diet, and then gain it back.
Yves Grant is a 50-year-old technical writer who joined Noom in 2019 after seeing a Facebook ad. “I was the type of person that never had to watch my weight because I had a high metabolism or whatnot; I could eat whatever I wanted,” he says. “But at that time I was getting older and getting heavier.” He liked that Noom advertised itself as offering community support, and that it told him it wouldn’t be a diet but a lifestyle change.
In practice, Grant says, Noom didn’t quite live up to his expectations. He thought he’d get more personal attention and concrete tips from his health coach, who he says mostly offered reflective questions. While the daily psychological tips were useful, they rapidly got overwhelming.
But the food tracking and calorie restriction, he says, really were useful. Between May and August 2019, he lost 30 pounds, and he says he grew to enjoy the feeling of hunger.
After that initial drop, Grant’s weight loss plateaued. Around April 2020, he lost interest in Noom and stopped logging in, and he never renewed his membership. Now, he says he’s gained back half the weight he lost, in part because he found the diet unsustainable. “Never eating potato chips, never?” he says. At one point on Noom, he began keeping a list of all the foods that he loved and felt he could no longer have.
Still, Grant doesn’t blame Noom for his regained weight so much as he blames his own bad habits. If he wants to lose weight again, he says, he knows what he has to do.
“They work for me!” he says. “I’d love to see them succeed.”
The anti-diet movement has been around since at least the 1960s, but only more recently has it begun to acquire cultural cachet, due in large part to social media. It has many branches: anti-diet, fat acceptance, body positivity, body neutrality. It’s been pushed forward by dozens of journalists and food professionals and bloggers and authors. In recent years, nutritionist Christy Harrison’s book Anti-Diet helped mainstream the concept of intuitive eating, while the popular podcast Maintenance Phase from journalists Michael Hobbes and Aubrey Gordon has been debunking the junk science behind diets.
At the center of the anti-diet movement are two scientific claims. The first is that the relationship between weight and overall health is unclear, and that it’s possible to be both a healthy fat person and an unhealthy thin person. The second is that most of the time, dieters end up gaining back all the weight they lost and then some within five years of the initial diet. So even if it were clear that being thin is important for health, that information wouldn’t do much for most fat people.
The data on the first claim shows it to be mostly true, with caveats. A 2014 meta-analysis in the scientific journal World Obesity found that between 6 percent and 75 percent of those classified as obese were “metabolically healthy,” depending on the definition used for “metabolic health.” Another meta-analysis, this one in the Journal of the American Medical Association in 2013, found that while those with a Body Mass Index (BMI) of 35 and above had a higher mortality rate than those with a BMI considered normal, lower grades of obesity were not associated with a higher mortality rate, and those who were moderately overweight had a significantly lower mortality rate. (Per the Centers for Disease Control and Prevention, a BMI of 18.5 to 25 is considered normal, and 30 and above is considered obese.) Finally, a third meta-analysis in 2014 found that overweight and obese people who were fit had similar mortality risks as normal-weight people who exercised, while people who didn’t exercise had twice the mortality rate, regardless of BMI.
All of these studies may be impacted by fatphobia, which, as Sole-Smith wrote in Scientific American in 2021, “shows up in the questions that researchers don’t ask” — questions like what other risk factors might disproportionately affect fat people, such as poverty, smoking, or the unhealthy effects of yo-yo dieting. Fatphobia even affects the way we measure obesity. While our medical system is built on the idea of the Body Mass Index as an effective measure of obesity, the BMI was originally designed to study populations, not individuals, and was based entirely on the average height and weight of white European men. The CDC and National Institutes of Health adopted their current BMI standards for obesity in 1998, on the advice of a private organization whose top donors were pharmaceutical companies making diet pills.
The data on the second claim is much more straightforward. Studies consistently show that it is very, very rare for dieters both to lose weight and to maintain their weight loss. One 2015 study published in the American Journal of Public Health found that for people classified as obese, the probability of attaining a BMI-normal weight is 1 in 210 for men and 1 in 124 for women. For people classified as morbidly obese, the probability goes down to 1 in 1,290 for men and 1 in 677 for women. Another 2015 study in World Obesity found that nearly all dieters gain back the weight they lose within five years, and one-third regain more than they lost.
While the science around weight is murkier than anyone would like to admit, there seems to be a fairly clear reason why dieters tend to regain their weight so consistently: Human bodies don’t like scarcity. If you restrict your calories, after an initial period of losing weight, studies suggest that your metabolism will slow. It will become easier, not harder, for you to put on weight. And your body will crave more calories, with more and more strength, until you break your diet and, often, find yourself binge-eating uncontrollably.
So why, anti-dieters want to know, do we bother dieting at all? Why have we allowed an entire industry to rise up around telling people to do this impossible thing, especially if it’s not clear that it’s even medically necessary? What do we get out of dieting except alienation from our bodies, a deeply disordered relationship to food, and a dysfunctional metabolism?
In fact, anti-dieters argue, dieting can damage the very bodies it promises to heal. In addition to slowing the metabolism, frequent dieting is associated with higher mortality rates and can double the risk of death by heart disease in patients with coronary artery disease. It can also damage the mind. One study finds frequent dieting is associated with high rates of depression. Dieters can become overwhelmingly fixated on food. In the Minnesota Starvation Study of 1944, 36 male volunteers were kept in a state of semi-starvation for six months on a 1,570-calorie-a-day diet. Before long, they became obsessed with food, fantasizing about it and discussing it at all hours. Now doctors consider extreme preoccupation with food a symptom of starvation, in part because of this study.
Moreover, the boundaries between dieting and eating disorders can easily become porous. Anti-diet books like Intuitive Eating are pitched to dieters who have found themselves estranged from their body’s hunger and satiation signals and need to relearn how to eat. Meanwhile, in the pro-ana forums and hashtags where self-identified anorexics enable one another, posters brag about teaching themselves to enjoy the feeling of hunger.
In 2016, a woman who we’ll call Amy finished her graduate degree in nutrition and her dietetic internship, making her a board-certified dietician. It wasn’t an easy journey for her. “It’s not uncommon for many people in the nutrition field to get there by way of their own disordered relationships with food, and I’m definitely in that camp,” she says.
Amy’s plan was to help other people take control of their relationships with food, in the way she craved taking control of her own. They would all learn to eat less and more healthfully, to keep their bodies slim. As she kept exploring nutrition after graduating, Amy began to encounter new ways of thinking about food.
First, she learned about mindful eating, the practice of paying close attention to the food you eat and your body’s response to it. From there she learned of intuitive eating, the practice of rejecting all food rules and allowing your body to guide your eating. Then she began hearing about Health at Every Size, the movement that argues that it’s possible to live a healthy life no matter what your weight is.
“I started reading the research from that lens, rather than my very much weight-biased lens,” Amy says. “Everything started to line up and I was like, ‘Oh my gosh, this makes so much sense.’ It really turned my world upside down.”
Amy was fascinated enough by what she learned about intuitive eating and body positivity to want to incorporate both into her growing practice as a nutritionist. She wanted more experience using both of them under someone else’s supervision before she was ready to go into private practice. When she heard about a promising weight loss company that seemed to be using a lot of the rhetoric of intuitive eating, she jumped at the chance to interview for a job there.
In March 2018, Amy began working as a health coach for Noom. “I was optimistic that there would be opportunities to use intuitive eating, especially since they incorporate it in their curriculum,” she says. Now, she says, “I think I was probably lying to myself.”
(Amy asked not to be identified by her real name due to a nondisclosure agreement she signed with Noom. Vox has verified her employment with the company.)
As Amy put in her time at Noom, she found herself gradually losing faith in the company.
The health coaches, she says, were perennially understaffed. While the company’s goal was to have each coach working with 300 users a week, at peak season, Amy says she found herself handling 800 active users a week. In an emailed statement, Noom said, “We don’t publicly break out the ratio of Noom Coaches to users, but caseloads are closely monitored to ensure that all users are receiving the support they need to reach their goals.”
Amy says the staff received a cash bonus for the extra work, and she thought all her colleagues were supportive and well-intentioned. She was worried, though, about the users she was supposed to be coaching.
“They were starting to see that they’d lost some weight but now they were gaining some back,” she says. “They were having a lot of difficulties. They were having a lot of food preoccupation. They were having all these really classic signs of starvation.”
Amy tried to work closely with the cases she was assigned to. She would tell them that the calorie budget they had been assigned was a minimum, not a maximum, to try to keep people from starving themselves. Still, she found herself fighting against the design of the app, which flared bright red warning signs whenever users went over their calorie budgets. The high workload also meant she never had time to pack all the nuance into her conversations with users that she wanted to.
In September 2018, HuffPost published a feature story from future Maintenance Phase co-host Michael Hobbes titled “Everything You Know About Obesity Is Wrong.” It was widely read and widely shared across the internet, including inside of Noom.
“That was one of the biggest articles that had come out in the mainstream [news] since I had been aware of the [size-]inclusive paradigm, so that was really exciting for me to see it getting that kind of coverage,” Amy says. However, “the response to it at Noom was not satisfying to me.”
In his article, Hobbes argues that our culture’s overwhelming focus on shaming fat people into losing weight is cruel, unproductive, and anti-scientific. “It’s time for a paradigm shift,” Hobbes wrote. “We’re not going to become a skinnier country. But we still have a chance to become a healthier one.”
Amy says that she had a productive conversation about the article with her supervisor, and that she saw plenty of her colleagues discussing it in good faith. “People were starting to question some of the things that overall Noom was perpetuating,” she says.
Ultimately, though, Amy felt that Noom’s response to the article was dismissive. That, she says, is when she knew she couldn’t stay at Noom.
“It really just started grating on me, the whole curriculum they have, the way they explain it. Hearing their ads on NPR basically any time I turned the radio on,” she says. “It just got really frustrating to hear the message over and over again that ‘we’re not a diet’ when they very clearly are.”
Shortly after the HuffPost article came out, Amy transitioned from full-time to part-time. Six months later, she had enough money to leave for good and focus on developing her private practice as an anti-diet dietician.
Meanwhile, Noom was flourishing with the onset of the pandemic. Stressed stay-at-home workers began obsessing over whether they were putting on the “Covid 15,” and Noom was ready and waiting for them.
As Noom kept scaling up, the backlash was building. In January, Alina Stone tweeted, “every noom ad is like ‘we’re NOT a diet. we’re an eating disorder :).’” The joke was enough to get Noom trending worldwide, with former Noomers sharing their stories in the replies. (In an emailed statement to Vox, Noom director of communications Sara Cohen said, “We take eating disorders extremely seriously and have since the earliest days of building our product.”)
every noom ad is like “we’re NOT a diet. we’re an eating disorder :)”
— big red (@spalinabean) January 25, 2022
“I was just kind of tired of hearing the ads and tired of them pretending they were not a diet,” Stone says in a Zoom interview. “It was constant, in podcasts and on YouTube. And it’s really hard to skip the ads on YouTube! They can use these buzzwords and catchphrases all they want, but it’s a diet.”
For ex- Noomers, the anti-diet nutrition principles that the company claimed to teach aren’t quite neutral territory anymore. In her private practice, Amy says she regularly sees clients who went through Noom’s program. When she tries to introduce intuitive eating concepts to them, she finds that she tends to have problems.
“It takes a lot of work to go through these lessons again,” she says. “They’re like, ‘Oh, yeah, I understand that.’ And then when they’re talking, it’s kind of like, ‘I’m hearing that you don’t [understand it],’ because of the way that Noom has discussed some of these topics. It’s really keeping people in this disordered relationship with food.”
Sonya Renée Taylor, the founder of The Body Is Not an Apology, says she wasn’t surprised to see Noom present itself with co- opted anti-diet language. “I expect capitalism to capitalize,” she says. That doesn’t mean, she adds, that Noom isn’t hurting people.
“At the end of the day, any modality that tells you that somehow you’re wrong, that your natural body cues are failing you, and that somehow you’re going to opt into a better life by being some other kind of body can’t do anything but fuel oppression,” Taylor says. “And anything that fuels oppression is inherently, innately harmful.”
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Father : “That’s great son. Who is she?”
Son: “It’s Tina, the neighbor’s daughter”.
Father : “Ohhh I wish you hadn’t said that.I have to tell u something son, but you must promise not to tell your mother.Tina is actually your sister.”
The boy is naturally bummed out, but a couple of months later
Son : “Daddy, I fell in love again and she is even hotter!”
Father : “That’s great son. Who is she?”
Son: “It’s Peny, the other neighbor’s daughter.”
Father : “Ohhhh I wish you hadn’t said that. Peny is also your sister.”
This went on couple of times and the son was so mad,he went straight to his mother crying.
Son : “Mum I am so mad at dad ! I fell in love with six girls but I can’t date any of them because daddy is their father!”
The mother hugs him affectionately and says:
"My love, you can date whoever you want. Don’t listen to him. He is not your Father.
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The volunteer in charge of contributions called him to persuade him to contribute. “Our research shows that out of a yearly income of more than $600,000 you give not a penny to charity. Wouldn’t you like to give back to the community in some way?”
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It tastes the same but it’s just not right.
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When I brought my black girlfriend home to meet them, my wife and daughter wouldn’t even talk to her!
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High Jacking
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