Group Weight Loss and Multiple Screening

This is a preprint of an accepted article scheduled to appear in the Bulletin of the History of Medicine, vol. 92, no. 3 (Fall 2018). It has been copyedited but not paginated. Further edits are possible. Please check back for final article publication details.

Group Weight Loss and Multiple Screening:

A Tale of Two Heart Disease Programs in Postwar American

Public Health

NICOLAS RASMUSSEN

SUMMARY: In the late 1940s, amid elevated concern about heart disease and new funding to fight it, multiple screening emerged alongside group psychotherapy for weight loss as two innovative responses of the American public health community. I describe the early trajectory and fate in the 1950s of both programs as shaped by the ongoing political controversy about national health insurance. Group weight loss became the main de facto American response to a perceived obesity-driven heart disease crisis. The episode casts light on the larger picture of how postwar American public health gravitated toward interventions centered on individual behavior and may offer lessons for obesity interventions today.

KEYWORDS: obesity, public health, history, Paul Dudley White, David Rutstein,

Louis Israel Dublin, Framingham study, epidemiology, group therapy

The dramatic expansion of biomedicine in the postwar United States has long attracted the attention of historians. With many in Congress wishing to show concern for the nation’s health, without running afoul of organized medicine’s fierce opposition to President Truman’s 1948 health reform initiative, generous federal research funding to conquer disease in the future emerged as a bipartisan project that substituted for funding to fight illness in the present. Thus the National Institute(s) of

Health (NIH) expanded from one to seven institutes between 1947 and 1950, while the budget grew from $8 to $53 million. Historians have not devoted equal attention to the changes brought with this rapid expansion across the various fields of biomedicine.1 This essay takes a step toward a better understanding of the shape assumed by public health research and intervention on heart disease by looking at the range of responses by the U.S. Public Health Service (PHS), and the broader

American academic public health community, in the late 1940s and early 1950s. In particular I look at the fate of two major new public health programs tested and introduced in this period, born of a sudden surge of interest in cardiovascular and other chronic diseases: multiple screening for heart disease and its signs, and group psychotherapy for control of obesity (understood as a contributor to heart disease). I argue that screening, initially viewed as most promising, was hobbled by the hostile political and fiscal environment for public health that followed on the clash over national health insurance around 1950. In contrast, group weight loss flourished because it was cheap and precipitated no resistance from clinical medicine. The episode sheds light on the shifting problems, ambitions, and constraints that shaped

American public health in the 1950s. It may also offer insight into responses today

toward the greater obesity epidemic that silently developed until recognized (again) in the 1990s.

Political Interest in Heart Disease

The expansion of heart disease research was a core element of the sudden general enthusiasm for science sweeping the American polity at the end of the Second World

War, and public health researchers stood alongside surgeons and laboratory workers set to benefit. A well-remembered sign of that enthusiasm was a report (and soon after, a best-selling book) called Science: The Endless Frontier, dramatizing science’s wartime contributions not just to national defense, through weapons such as radar and the atom bomb, but also to medicine. Penned with encouragement from the White

House by Vannevar Bush, an MIT dean who had led one of the most visible wartime research agencies, the book argued that generous government funding of academic science should continue. Although opinions differed greatly on how best the federal largesse should be distributed and managed, the main idea was very well received and immediately taken up by congressional advocates of research.2

One of these was Senator Harley Kilgore who in October 1945 called David

Rutstein, a New York public health official and rheumatic heart disease expert, to testify before his science committee on the importance of heart disease and on the need for more funds for a rheumatic heart disease research and intervention initiative

Rutstein was planning on behalf of the American Heart Association (AHA). The

AHA at the time was trying to reinvent itself as a major research patron, and Rutstein had been invited through the Association’s public relations representatives,

presumably in response to senatorial interest in showcasing heart disease work that was languishing for lack of money. AHA representatives including Rutstein (an AHA executive employee in 1946–47 before assuming a Harvard professorship) would testify before congressional science and health committees numerous times over the next few years about what could be done to fight heart disease—the nation’s leading cause of death by far.3

Rutstein and fellow AHA leaders were summoned to Washington in the spring of 1947 to confer with Surgeon General Parran, Senator Claude Pepper, and

Congressman Jacob Javits to help draft a bill that would establish a heart disease institute within NIH.4 This bill would be signed into law as the National Heart Act in mid-1948, following on the heels of a stunningly successful AHA fund-raising drive that proved the nation willing to spend much more to fight heart disease. It was helped along by the powerful cabal of congressmen and lobbyists promoting the expansion of biomedical research more generally, including Mary Lasker, a friend of the AHA and formerly a key figure in the successful campaign to establish the

National Cancer Institute in 1937. The 1948 Heart Act did the same for heart disease, creating the National Heart Institute (NHI).5

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In early May 1948, with the Heart Act on its way to Truman’s desk, the national

Sunday newspaper supplement Parade carried a feature titled “Wanted: Better Public

Health,” authored, rather unusually, by a high federal official named Oscar Ewing. In it, the chief of the Federal Security Agency (FSA), parent agency of the Social

Security Administration and PHS (including NIH), publicized the ongoing National

Health Assembly, a conference of health policy experts he had convened at Truman’s request to develop a comprehensive health plan for the nation. Ewing’s piece opened by attacking the commonplace, complacent belief among Americans that they were

“the healthiest nation in the world.” The United States ranked behind other developed nations in combatting tuberculosis and many other major causes of death, he noted, and in the recent war five million draft inductees had been rejected as unfit and another three million discharged for preexisting health reasons. And no wonder that

10 percent of the nation’s young men were too unhealthy to serve, urged Ewing, given the shortage of doctors, dentists, and nurses in many parts of the country, and a third of the population lacking “organized public health services” altogether. Noting that cancer research, then accounting for over half of the $28 million federal budget for medical research, was “making good use of every penny,” Ewing joined his voice to many others then arguing for much more federal research funding to fight other diseases—beginning with heart disease, the top killer, and mental illness, sometimes estimated to cost the economy the most. And the Truman administration, for whom

Ewing spoke, planned that the federal government should take an even greater part in improving the public’s health directly, through conjoined initiatives to provide both preventive services and health care—through the FSA and very possibly PHS.6

A major architect of Ewing’s National Health Assembly was epidemiologist

Louis Dublin, a vice president of Metropolitan Life Insurance and past president of the American Public Health Association (APHA), who devoted his career to studying and fighting the chronic diseases that had displaced acute infections as the leading causes of ill health. When he accepted Ewing’s invitation, he hoped that “a (broader) public health program for the country as a whole” finally would come from the

Assembly—here evincing the attitude shared by many proponents of the “New Public

Health” that emerged in the 1920s, according to which that field should manage the state’s approach to health as whole, so that preventive services, clinical care, and many aspects of the built environment would be coordinated for optimum and cost- effective health outcomes. Soon Dublin felt disappointed that Ewing replaced most of the experts he recommended for the leadership with “a lay committee representing consumer groups.” But concretely, what emerged from Ewing’s Assembly was essentially an updated version of the plans sketched at the National Health

Conference of 1938, in which Dublin also played a central role. Crafted by public health leaders, this plan featured locally governed health councils through which health departments would coordinate comprehensive health services including hospitals and physician care—funded federally through a national health insurance plan to be integrated into Social Security. Dublin had long advocated coordination and expansion of health insurance coverage to near universality, and was among the many like-minded public health leaders bitterly disappointed when President

Roosevelt did not make enacting the Health Conference’s reforms a priority.7 But they became a key plank in the Democratic election campaign in 1948, and revised as the “Ewing Plan,” the basis for the Truman administration’s health policy. The medical profession in 1948, taking JAMA editor Morris Fishbein as its voice, recognized the same program of “socialized medicine” it had fiercely opposed earlier, and predictably denounced the “emetic” of “compulsory sickness insurance” (as the

AMA preferred to call it). A monumental clash was coming.8

The 1948 National Heart Act, which Ewing also personally advocated, was not just about the NHI; it displayed all the same ambiguities, conflicts, and mixed

motives of the greater postwar biomedical expansion that spawned it. Its express purposes were to “improve the health of the people of the United States through the conduct of research” into the causes of heart disease, to improve physician training and facilities for diagnosing and treating heart diseases, and furthermore to support

“development of community programs for control of these diseases”—that is, public health efforts to reduce the burden of heart disease. There was overlap here with the

New Deal health reform agenda that Truman inherited. Apart from near universal health care coverage, three of the other key thrusts spelled out by the 1938 National

Health Conference were the expansion of existing federal public health services, the expansion of hospital facilities via federal grants, and federal funding to states for indigent medical care. All three topics were abundantly present in the congressional discourse around the Heart Act’s passage and likewise in its wording, so it is no surprise that initiatives speaking to public health and prevention and even some care provision all issued from the Heart Act, sometimes mixed with research. The Heart

Act thus offered new money for favored projects across the political spectrum: enhanced government-funded public health and care programs pleasing to those welcoming an expanded direct federal role in health; subsidies and grants for teaching, advanced training, medical schools, and hospital facilities, all favored by physicians; and also funding for scientists working to conquer this leading killer both at universities and at the NHI in Bethesda.9

While creating the NHI within the NIH (of the PHS), the Heart Act also stipulated that PHS’s chief, the Surgeon General would rely upon a newly created

National Heart Advisory Council (NHAC) to decide upon the disbursement of heart funds. This Council included government officials from the PHS and, in greater

numbers, representatives of medicine (mainly AHA officers) and the lay public (such as Lasker). Harvard cardiologist Paul Dudley White was selected as the chair, a choice that balanced the triple demands of the moment—that the federal government support science, the practice of cardiovascular medicine, and public health. In essence, through White, the United States placed its national heart disease effort in the hands of the AHA. Effectively the dean of American cardiology, White had built a distinguished thirty-year record as a researcher and was a foremost authority on electrocardiography. He had huge credibility with clinicians as well as researchers, having taught many of the nation’s heart specialists both directly through traineeships at Massachusetts General Hospital and indirectly through his influential textbook. But as a longtime active member of the APHA, he was also intimately involved with public health initiatives (such as Rutstein’s rheumatic program mentioned above, planned within AHA while White was its president).10

White would proceed cautiously, crafting a consensus about what heart disease research and control activities the PHS should fund. He began by organizing a series of 1949 meetings involving virtually all the influential clinicians and researchers in cardiovascular medicine, and many from public health and other domains as well. The process culminated in a National Conference on Cardiovascular

Disease, held in Washington in January 1950, under joint auspices of the AHA, NHI, and White’s NHAC.11 From that conference a set of concepts, approaches, and program types officially endorsed for NHI support would be issued, as we will see.

But even before the Heart Act was signed in mid-1948, public health leaders were taking advantage of the favorable new atmosphere.

In an August 1947 Washington meeting on how to spend a special

appropriation of $500,000 for heart disease that had arisen from discussion between

Senator Pepper and his congressional allies with AHA representatives (including

Rutstein), Joseph Mountin, PHS’s chief epidemiologist at the time, described at length an “epidemiological field study on the incidence of cardiovascular disease” being planned by his subordinate Gilcin Meadors. At this meeting Rutstein, who had just been appointed a professor in preventive medicine at Harvard, proved “much interested” in the project and in conducting it near Boston. Meadors’s project would become the famous Framingham study on heart disease epidemiology. However, the plans discussed at that meeting involved much more than purely observational, prospective epidemiology, and Rutstein would be thoroughly involved.12

Both mass screening and group obesity control measures can also be traced to this planning meeting. Originally, Mountin and Meadors’s plan explicitly included screening alongside its main focus, the correlation of risk factors from initial examinations with later morbidity and mortality in order to probe the causes of heart diseases. A large sample of adults in a nationally representative town—mostly white and not recently immigrated—would be carefully examined and then followed up with one repeat examination after five years. The initial examinations would include a detailed family and medical history and assessment of features including height, weight, blood pressure, and mental tension, plus several urine and blood tests including serum cholesterol (obesity, hypertension, and cholesterol, along with anxiety and diabetes, all being widely suspected factors in the development of coronary heart disease, CHD, the most common specific cause of heart disease death).

They also would include a set of “objective” physical measures of cardiovascular function by technicians (e.g., electrocardiograph, chest X-ray, and a new device called

the electrokymograph). The correlation of these instrumented measures with heart disease on follow-up would be a test of their utility for mass screening, usable in the same way as the mobile chest X-rays recently introduced and widely used for mass tuberculosis screening at the time.13

By the next month, with PHS encouragement, Rutstein and his friend Vlado

Getting, Massachusetts’ health commissioner, were already planning that Meadors’s study should take place in Framingham, Massachusetts, a community that had hosted a successful tuberculosis (TB) control pilot program from 1916 to 1923. The goal of that program, jointly created by the National Tuberculosis Association and

Metropolitan Life Insurance, had been “to discover all cases of tuberculosis in the community, to determine the economic and social factors in disease causation with special reference to tuberculosis, to apply the best-known methods of treatment, to develop a comprehensive programme of prevention, and organise the community for disease prevention and health creation.” Young Louis Dublin, in his early position within Metropolitan’s activist Welfare Division, had played a leading role in designing it as a test of the New Public Health principle that prevention and education

(both lay and professional) coordinated by local health officers, along with service delivery including physician care, could yield concrete dividends—which it did, halving TB death rates in Framingham compared with control towns by 1924.

Rutstein, the former health department executive and designer of the AHA’s first major public health intervention, may have been imagining a similar program to remake health care systems on a city scale, treating the epidemiological study as a

“community diagnosis” (as the Metropolitan investigators called theirs)—whose chief purpose was not scientific hypothesis testing about disease causes, but as an adjunct

and guide to immediate prevention and control efforts. His subsequent heart disease research projects certainly suggest an interventionist bent, as we shall see.14

Whereas a combined epidemiological survey and demonstration intervention in Framingham suited Rutstein, by the end of 1947 the PHS separated these into distinct projects: a heart disease control program led by Lewis Robbins and the epidemiological study led by Meadors. While still reporting to Bert Boone, the PHS

Heart Disease Demonstration chief and the electrokymograph’s inventor, who was based in Philadelphia, both were assigned to Massachusetts and located at Harvard nominally under Getting’s and Rutstein’s authority (until transferred in mid-1949 to the NHI). The reasons for this separation are unclear; Boone’s job position indicates that for the PHS the epidemiology and control aspects were originally combined, and

Meadors later blamed Rutstein for “alienating” the two aspects of the program, in a letter to high PHS superiors. However this “alienation” may have been a tactic of

Boone and Meadors to protect the epidemiology program from subordination to

Rutstein’s disease control agenda. In any case Boone came to agree with Meadors and

Robbins that “Dr Rutstein should not be the basket in which all our eggs lie” when he, with Mountin and Estella Ford Warner, head of state relations in PHS, formally split the disease control demonstration from the Framingham epidemiology study and moved the former to another town yet to be designated. Friction continued between

Rutstein and Meadors into 1948, when the Framingham study actually got under way—Meadors resenting what he considered micromanagement by his “technical advisor” Rutstein, while Rutstein regarded Meadors as working for him and Getting

(formally true at the time). This clash contributed to Meadors’s eventual replacement.15 Since a number of historians have already discussed Framingham, I

will leave it aside to focus on obesity and on mass screening—which soon faded from the evolving Framingham study.16

Rutstein began shifting his interest to the heart disease control project, by June

1948 slated for Newton, Massachusetts. A draft plan from around this time was sketched, in consultation with Rutstein, by the state’s chronic disease division under

Herbert Lombard. Lombard had led a cancer control demonstration in the late 1920s that, as Daniel Fox has put it, became “a handbook for subsequent chronic disease surveys and control programs” and, like Metropolitan’s Framingham TB study, another showpiece for the New Public Health. That demonstration featured a high- profile professional and lay education program to increase awareness of cancer and its signs, publicly funded diagnostic clinics from which newly discovered cases would be referred to physicians, social workers to follow up cases and coordinate services for them, publicly funded cancer hospital beds, and careful record keeping of each cancer death for epidemiological study (but not a complete registry of all cases, unlike the

Framingham TB intervention). Especially important had been tactics to enroll the local medical profession and public, including appointment of both lay and medical steering committees. Lombard’s 1948 heart disease plan contained many of these features, emphasizing lay education in heart disease, professional education, development of cardiology clinics meeting AHA standards, expansion of such public health services (rehabilitation, nursing, nutritional advice) for heart patients as their physicians might recommend, establishment of a heart disease registry to enable epidemiological data-gathering—all of which had featured prominently in Rutstein’s

AHA rheumatic project too. With Rutstein’s advice, a program of cardiological case- finding was removed from an early draft, but soon was reinstated in the plan, after

consultation with the Newton physician community as represented by the local medical club.17 We shall soon return to the Newton demonstration project, which featured the debut of group weight loss among its several programs.

Rutstein was certainly not opposed to case-finding efforts, any more than the

PHS had been in its pre-Framingham plan (partly conceived, after all, to test Boone’s electrokymograph and other methods of screening for incipient heart disease). Indeed the idea of mass screening was at the forefront of his field, preventive medicine—the intersection of public health and medical practice. Mass screening had begun during the war with mobile chest X-ray surveys for TB, now extended so as to identify other chronic disease cases at the same time.18 Here, in testing that was both quick and cheap, and typically offered free, there was promise of efficiently extending the periodic medical examination’s benefits of early disease detection and treatment to the whole population. One pioneer of multiple or “multiphasic” screening was Lester

Breslow, who in 1946 became the first head of the California health department’s chronic disease branch. In 1949, in collaboration with other state and local public health officials, he set up a pilot project that took chest X-rays, blood samples, and urine samples from nearly a thousand volunteers in four industrial plants near San

Jose, examining all for signs of lung disease, heart disease, kidney disease, diabetes, and syphilis. If the new Papanicolaou (Pap) test for early cervical cancer were included in a panel of screening tests, he argued, screening every thousand adults would discover “20 to 30 persons who have significant disease requiring the continuing attention of a physician.” The PHS applauded Breslow’s pilot studies;

A. L. Chapman, head of a new Chronic Disease Division within the PHS Bureau of

State Services, urged in a 1949 article that multiple screening was good for doctors by

directing new business to them, good for patients who would stay well and productive if chronic disease were detected early enough, good for taxpayers by reducing society’s disease burden, and good for public health officers, who would not only make progress against chronic illness but do so with a “tangible” service more easily appreciated by the public than milk inspection and clean water. Chapman proved overly optimistic about the doctors, and Surgeon General Leonard Scheele was not exaggerating in January 1950 when he described multiple screening as “difficult to sell” despite being “one of the most attractive programs the Public Health Service has initiated.”19 But the idea did appeal to public health departments venturing into chronic disease, and was immediately taken up by several of them with pilot screening projects in Indiana, Virginia, Georgia, Alabama, as well as Massachusetts.20

Massachusetts public health officials seem to have independently launched their own multiple screening project in 1948, when Lombard and Getting succeeded in securing the state medical society’s approval to establish several pilot screening clinics that would test for diabetes and heart disease together with some forms of cancer (including cervical), with subsequent referral to hospitals or private physicians.

In 1949, with funding from the Cancer Society, AHA, and now the PHS, these opened and continued operating into 1952—over time speeding and simplifying the tests so as to eliminate an examining physician entirely in favor of technicians and nurses.

The final version involved a self-completed medical history, height, weight, hearing and vision tests, simple blood and urine tests, occult blood and Pap tests for cancer, and, for cardiovascular disease, a blood pressure test along with a simplified electrocardiogram and chest X-ray (interpreted off site by a radiographer for both heart and lung abnormality). Recognizing that many “physicians . . . are inclined to be

critical and to fear the program as the foot in the open door of state medicine,”

Lombard and Getting framed multiple screening as a benefit to medical practitioners, who would acquire new patients.21 Like Chapman (above), Breslow too offered this conciliatory logic by insisting that screening results can never replace a doctor’s diagnosis nor even a periodic examination; rather they raised demand for services from private physicians and even induced “many persons, who would perhaps otherwise not do so, to select a personal physician.” Breslow was learning, however, that private practitioners still resented these screening tests as weakening the doctor- patient relationship (perhaps because they revealed disease where the doctor had failed to notice), and still feared them as the forerunner to “state medicine” (perhaps because the new cases created a demand for medical care far exceeding what private physicians could meet).22 This fear was particularly understandable during the

Truman administration’s 1948–50 campaign for the Ewing Plan.

Rutstein participated in the Massachusetts multiple screening demonstrations, conducting a satellite study with both PHS and state funding and AHA involvement.

Here he evaluated the use of the 75mm X-ray films recently introduced by the PHS for mass TB screening, finding that the reading of these same chest films in the course of a regular community TB survey for abnormal heart as well as lung shadows, followed by a confirmatory cardiological examination, discovered significant numbers of unsuspected heart disease cases. He also found that the regular PHS radiologists had roughly the same confirmation rate (69 percent) as specialist heart film readers (61 percent). To Rutstein the finding that 280 new cases of heart disease—about half of whom he judged would benefit from the diagnosis, for example, by going on a low-salt diet to reduce blood pressure—could be discovered

in 31,000 chest X-rays was a powerful argument for heart disease case finding in broader multiple screening programs.23 It fit well with the New Public Health concept, infused throughout Rutstein’s planned rheumatic fever initiative, of an integrated program where the local health department would coordinate prevention, case detection, therapeutic care and other clinical services, and rehabilitation. But who would attend to all the newly discovered heart disease victims so as to extend their lives, and save taxpayer money? The experts at White’s January 1950 National

Conference had endorsed mass screening, but noted that “there is limited value in case finding” unless affordable care and facilities were available to all the people in whom heart disease is discovered.24 Something like the Ewing Plan was essential to reaping full health benefits by these means. This difficulty would hamper the progress of screening in the general population—especially as compared with another approach to addressing heart disease that both Rutstein and PHS were developing simultaneously.

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In early 1949, approximately when the Massachusetts screening pilots were launched, the state received a PHS grant to support the Newton Heart Demonstration Program.

Commissioner Getting appointed Rutstein to its steering committee, whose chair was

Egon Kattwinkel, leader of the Newton Medical Club. Modestly echoing the interwar

Cancer Demonstration’s coordinated approach to detection, care, and prevention, the

Newton initiatives fell under five headings, each led by a subcommittee including local physicians: Physician Education, Community Organization (including lay education), Temporary Voluntary Reporting (i.e., creation of a case registry partly for

epidemiological purposes), Rehabilitation, and Nutrition. This last group initially concerned itself with the dietary needs of heart patients, but was redirected to the problem of prevention though a spirited May 1949 address in Newton by Rutstein.25

Obesity had by this time become widely recognized as a major predictor of coronary and other heart disease mortality, and very possibly its leading cause, through epidemiological studies by the life insurance industry, which at the time had unique access to the volumes of detailed data required for such analyses. Dublin’s first insurance job in 1908 was to update the weight/height tables used to determine the excess premium charged to overweight policy applicants, already a well-established practice due to their above-average mortality. The next year saw the beginning of data analysis in a sophisticated study called the Medico-Actuarial Mortality Investigation

(MAMI) by a consortium of insurance firms, correlating data from initial medical examinations with death rates among hundreds of thousands of policy holders. It was succeeded by the similarly designed, even larger Medical Impairment Study, which brought findings forward to 1928. Based on observation of millions of life-years, these studies carefully quantified the excess mortality from all causes among overweight people, especially men (as well as among smokers, heavy drinkers, etc.).26

In 1930 Dublin conducted another study of this type on 192,000 men, an especially uniform and favorable sample for analysis (free of confounding variables, in today’s terms). Dublin found that mortality rates increased with degree of overweight, as expected with exposure to any harmful condition: compared with men within 5 percent of average weight for their height, those only 5 to 15 percent overweight suffered a 22 percent higher death rate, and those 25 percent or more overweight 74 percent higher. Dublin also broke new ground by looking at particular causes of

death, noting that death certificate reliability had greatly improved, and found the excess mortality among the overweight to be due mainly to heart diseases. The association was dramatic: for all cardiovascular causes of death combined, men 5 percent or more overweight suffered mortality rates 50 percent greater than average weight men. Diabetes and kidney disease mortality were also higher. Subsequent insurance studies confirmed this picture, and also the alarming fact that average weights of adult Americans were creeping above the weight predicting lowest mortality. During the war years, Dublin’s Metropolitan team issued new weight/height tables reflecting the fattening American population, actuarially redefining normal or “ideal” weight as that predicting maximum life span.27

When Rutstein addressed the Newton Nutrition Subcommittee in May 1949 he stressed that obesity was certain, from such statistics, to be a major contributor to heart disease mortality. He also stressed the “psychological factor in obesity,” and that “pride, vanity, fear, competition and some of the principles of Alcoholics

Anonymous” could all motivate weight reduction in small therapeutic groups. Here

Rutstein evinced an up-to-date awareness of expert opinion about the nature as well as consequences of obesity. Over the past decade medical thinking had shifted away from an endocrinological perspective, according to which overweight commonly resulted from abnormally “slow metabolism” of glandular origin. The new perspective was psychiatric. Based on careful physiological studies showing that obese people had average (or higher) metabolic rates, and on a body of studies by psychiatrist Hilde Bruch and others, overweight and obesity were now understood as due to a neurotic overeating pattern with its origins in childhood. Indeed, according to the psychoanalytically influenced psychiatry of the day (which generally credited

Bruch with the discovery, even though her own ideas differed somewhat), the driver of the overeating behind obesity was typically an oral fixation reflecting failure to develop mature forms of psychosexual gratification, and was essentially identical to the cause of alcoholism and other addictive disorders.28 As for alcoholism, during the

1940s the Alcoholics Anonymous (AA) fellowship had risen to prominence and gained admiration among psychiatrists for its success in controlling this previous intractable addiction. Mental hospitals emulated AA in their group therapy for alcoholics and released patients into community AA programs, while psychotherapists studied AA as a source of technique and insight. AA co-founder

“Bill W” was even invited as a keynote speaker to the 1949 American Psychiatric

Association meeting. This admiration is all the more remarkable given that the AA fellowship was entirely lay administered and kept medical expertise at arm’s length, relying upon a frankly spiritual Higher Power as well as some pseudo-scientific concepts (such as alcohol allergy).29

Within a few weeks of Rutstein’s proposal, a trial of a weight loss intervention inspired partly by AA had been designed and launched in Newton. In it thirteen people referred by their physicians, all middle aged and over their “ideal weights” by at least 15 percent but otherwise healthy, met weekly for a group discussion moderated by the program nutritionist; after six weekly sessions, another six followed fortnightly. In the end, eleven of the twelve completing participants in the “group- discussion” pilot study lost weight, and five reached their ideal weight.30 This study excited great enthusiasm, even before it was actually under way. In late May 1949 the

Newton Heart Demonstration leadership already professed that its three most promising opportunities in prevention were rheumatic fever control programs in

schools, reducing bacterial endocarditis though antibiotic prophylaxis for recovered rheumatics, and for coronary disease the “control of obesity.” In obesity they saw a problem “almost as difficult as that of keeping an alcoholic sober” and “techniques of

Alcoholics Anonymous” to alter individual eating behavior the best option, given the profound “difficulties in achieving results by public health methods.” (Here “public health methods” presumably meant population-level interventions, not impossible to imagine for obesity control; for instance, advertising controls on candy and soft drinks modeled on alcohol regulation were proposed in 1942 by a surprisingly progressive

AMA Council on Foods and Nutrition, on the grounds that sugary foods with low nutritional content cause widespread health harm.) All of this fit well with Rutstein’s thinking. In 1948–49, in a review of public health approaches to heart disease control, weight reduction was the only preventive measure Rutstein endorsed for both essential hypertension and arteriosclerotic heart disease.31

Rutstein is unlikely single-handedly to have invented the notion of group weight loss, combining the AA concept of a mutually supportive confessional fellowship together with the emerging trend among psychiatrists of group therapy.

Just four months after the Newton experiment, in October 1949 a larger, similar study was under way nearby at the Boston Dispensary (of the New England Medical

Center). In this study, a joint project of the PHS and Massachusetts Health

Department, overweight volunteers were assigned to nine groups, which met for sixteen weekly sessions under a variety of discussion leaders or moderators. At the end of the four months of group participation, the investigators reported that of those finishing the program and followed up, the majority lost ten pounds or more (although that majority was a minority of those enrolled initially). Some groups elected their

own leaders and continued meeting regularly.32 Two distinct sources can be traced for the group approach as applied in this study. One was a particular type of health education class that originated at the Dispensary itself between the wars. There tuberculosis TB specialist Joseph Henry Pratt had led regular meetings, known sometimes as the “thought control class,” to manage mainly psychosomatic complaints among clinic patients. These meetings, closely controlled by the charismatic Pratt or another medical authority, have been described as an important forerunner of cognitive behavioral therapy in the United States.33

Another source for the Dispensary approach was group psychotherapy, which overworked military psychiatrists had first adopted to treat traumatized mental health casualties and then veterans of the Second World War. Psychiatrist Benjamin Kotkov of the Veterans Administration hospital in Boston helped adapt for weight loss some specific group techniques developed for veterans suffering neurotic emotional disturbances. With veterans Kotkov had used group discussion to help diminish

“feelings of uniqueness, stigma, and isolation.” Participants were asked to conduct

“self-inventory” to foster “self-growth and self-understanding” through work as “a team and on a buddy level.” This teamwork among the veterans amounted to voicing anxieties, “unacceptable impulses,” masturbation habits, and so forth, driven by the idea that recognizing similarities among the others would help each participant accept and manage his own demons.34 As adapted for the Dispensary, group discussions followed the same general confessional format to break down each fat person’s terrible “loneliness,” born of their sense of unique “unworthiness” and that their thoughts are “bad, dirtier” and “inferior” to anyone else’s. There seems to have been less emphasis on sex, understandable given that the groups were mixed-gender and

mostly female; also, group discussion was not supplemented with individual psychotherapy (as the veterans’ was). Gradually, participants shared their fears, hostilities, lack of self-respect, and the situations and emotions making them overeat, eventually gaining insight that would help their own weight loss. Although such distinctions would not become rigid until the late 1960s, when various schools of group therapy solidified, the Boston Dispensary approach was more “treatment of individuals in a group” as opposed to “through a group,” in that it sought similar individual insight for each participant by making individual group members serve as examples for one another. For Kotkov, the therapist acted less as a leader than as a

“permissive parental figure” and catalyst, encouraging participant-initiated mutual assistance. Indeed, unlike the Pratt classes and standard group psychotherapy, this study made a point of showing that the group moderator need not be a psychiatrist or other health professional with special expertise.35 In this way, the Dispensary group weight loss pilot was also vaguely inspired by the more thoroughly leaderless practices of AA.

Here was an idea whose time was ripe. Before the results of the Boston and

Newton studies were first published in May 1950 public health officials elsewhere were calling for the establishment of an “Appetites Anonymous” nationally to fight obesity. Obligingly, a weight loss society called Fatties Anonymous was established that year, based closely on AA principles, by a New Yorker named Ruth Douglas.

Still earlier, perhaps before public health professionals first considered the AA group therapy weight loss idea, in early 1948 a Milwaukee housewife named Esther Manz began meeting with overweight friends and founded a mutually supportive self-help club called Take Off Pounds Sensibly (TOPS). While Fatties Anonymous quickly

faded (and was not replaced by another weight loss club closely modeled on AA until

Overeaters Anonymous in the early 1960s), TOPS flourished and spread quickly through the Midwest. TOPS was fully lay administered and featured little psychiatric or other medical input, and little reliance on introspection and confession, instead using competition, games, and other play psychology techniques to motivate its members to diet.36 But at first TOPS received little notice from the public health community, who instead found in the Newton and Boston Dispensary studies strong inspiration to launch a wave of group weight loss studies and group therapy programs under closer expert guidance, as we shall see.

⬧

1950 was a watershed year for American heart disease control, and for public health more generally. January saw the National Conference on Cardiovascular Disease that

White had spent the past year orchestrating. The conference’s scope was great, including topics from specialist training, research policy, and medical and nursing education to assessments of the state of the art in physiological and epidemiological science about all forms of heart disease. The expert panel of epidemiologists effectively endorsed the narrowing Framingham study, calling for hypothesis-driven population “surveys,” especially in a representatively sampled population, to assess the emotional, nutritional, genetic, environmental, and especially physical (e.g., blood pressure, serum cholesterol, obesity) factors thought to contribute to heart disease.37

Both mass screening and weight control also stood out as especially promising among

White’s delegated experts in public health topics. The Case Finding and

Epidemiology Committee asserted that there existed “ample” knowledge to guide a

national heart disease control program, despite acknowledging the large gaps in knowledge of both the distribution and causes of heart disease, that Framingham would help address. For control of coronary disease, as for rheumatic fever, it recommended that public health programs should involve aggressive case finding coupled to mass screening programs, especially TB screening.38 For its part the Lay

Education and Prevention Committee proposed mainly to prevent heart disease with programs to educate the public about “weight control, body build, heredity, stress of modern living, smoking, drinking, periodic health examinations” (subject to endorsement of these factors by the scientific and clinical experts at the conference).

And the central scientific and clinical expert panel offered weight control as its chief recommendation from for a general prevention program aimed at CHD.39

As they had with the Framingham epidemiology study, these recommendations endorsed heart disease control programs already launched by leaders like Rutstein and backed by the PHS, such as the Massachusetts multiple screening program and Newton demonstration (which also included some screening, mainly at a Raytheon factory). PHS Heart Act funds for fiscal year 1949 had been too small to distribute nationally, so demonstrations had been funded in six states. Apart from Newton, the only other two heart disease control demonstrations from this first generation I have identified took place in Salisbury, Maryland, and Charleston, South

Carolina.40 Both involved screening. In Salisbury, a consultation clinic was provided for physicians to refer heart patients, and blood pressure was recorded during a mass

TB screening, with cardiological film reading for more than 1,470 hypertensives among 6,457 thus screened by mid-1950. In Charleston, a Heart Demonstration Unit was established in cooperation with the county health department and the local

medical society, as with Newton and Salisbury. During three years its major program was case finding in the schools and also in the general population, to whom a free brief physician examination was offered with blood pressure testing and a simplified electrocardiograph. Those suspected of heart disease were referred to their own physicians (after consulting the doctors, presumably without first telling the subjects their test results). Among 4,611 people examined, 189 confirmed new cases of heart disease or hypertension were discovered in this simple screening program. The other main intervention mainly consisted of special training for the school physicians, who then launched an unsystematic “survey” of school children for rheumatic disease.41

When the next year’s federal appropriation of $2 million for heart disease control opened the way for all states to apply for support, such modest activities began proliferating among PHS-funded heart disease projects. The particular initiatives state health departments supported with these funds now included their own pilot studies in group weight loss, along with lay and professional education, supplemental resources for existing heart clinics, consultant services where these were lacking, and case finding programs including multiple screening projects in tandem with TB screening.42

But the by the end of 1950, the newly bold and optimistic spirit with which the

American public health community had approached heart disease had ebbed. That spirit had been on show at the outset of planning for the National Conference in late

1948, in the meeting of an elite steering subcommittee that White had, which enunciated the principle that heart disease control grants to states should contribute to

“complete health programs for individual and community”—very much in tune with the New Public Health and Truman’s health initiative.43 As we have just seen, the

heart disease control activities actually undertaken by local and state health departments with PHS support were mostly modest. But it did not take long for these halting efforts at expanding the role of public health to evoke strong resistance. The greatest early conflict emerged around case-finding, particularly in the general population via mass screening. Rutstein expressed concern in August 1950 about certain unproven screening procedures being promoted by the Chapman’s Chronic

Disease division, and feared that when they became more widely publicized the multiphasic screening concept would be altogether discredited—and also open the

PHS to further “attack by the organized medical profession.”44 By October 1950

Rutstein’s fears were borne out when tensions around screening grew critical, in

White’s view, moving him to write an agonized memo both rebuking and pleading with the PHS and NHAC members concerned with heart disease control (such as

Chapman and Rutstein). Among private physicians White felt mounting antagonism and “fear . . . of invasion of their own privileges, rights, and opportunities” by the new heart disease control programs; he personally “found this situation threatening and sometimes exploding in several places, in particular in Illinois, Texas, and Hawaii,” and he believed elsewhere too. He sympathized with doctors “when, for example, it is proposed to establish diagnostic clinics where there are already excellent private clinics” with which the public clinic might compete; such clinics only “should be established with the approval of the local medical profession.” Further, White scorned

“the current fetish” of newer screening techniques “such as ballistocardiography or fluorokymography or electrokymography or mass x-ray detection of tuberculosis or even cardiac catheterization”—all of which he regarded as experimental or suitable only for limited use in hospitals. Rutstein must have been dismayed to see White

lump his chest X-rays together with other “fetishes,” for which he blamed Chapman.

White concluded by admonishing that “we must correct the situation,” and that an essential starting point would be to require that a “widely recognized and respected expert” in cardiovascular medicine “and not an administrative health officer alone” have responsibility for each state program. Still, in early 1951 the PHS, presumably under Chapman’s leadership, issued the instructional brochure “Multiple Screening” for local health departments, urging chest X-rays in tandem with electrocardiography

(as well as other tests) (Figure 1).45

White’s last suggestion was quickly implemented, making oversight by the local Heart Association a universal feature of state heart control programs, thus subordinating public health to the medical specialty of cardiology.46 One reason for acquiescence by the PHS can be found in the November 1950 federal election, just a month after White declared a crisis around screening. The American Medical

Association had worked together with the Republican Party to make the Ewing

Plan—“socialized medicine”—a winning “single issue aggressively sold to the voters” (as a Republican National Committee report put it). The propaganda barrage was intense, and although Democrats held on to a slim majority in both congressional houses, few politicians were now willing to risk their careers on national health insurance. The Ewing Plan was therefore a “dead duck,” as the Washington Post declared in its election analysis. Public health’s leaders, disappointed by the political annihilation of their dream of a coordinated system of publicly funded surveillance, preventive services, and clinical care, had to find ways forward more congenial to private practitioners.47

But physician hostility to public health lingered. Dublin’s fellow Metropolitan vice-president William Shepard, addressing the APHA as its president in November

1951, blamed the situation on Ewing for overreach and problematic political convictions, along with a few benighted physicians who entirely “fail to see the reasons for public health” work and “confuse [all] public health programs with what they call ‘socialized medicine.’” Only this hostile minority stood behind recent indignities, for example the blocking of community efforts to institute a visiting nurse service under health department auspices, state medical society resolutions against “a well-operated state health department program for the care of crippled children without offering a better method,” and in several states the “sponsoring [of] legislation designed to limit public health activities to five of six minimum basic functions.” Shepard urged public health professionals to join forces with friendlier doctors to meet the nation’s health needs.48 But as the Fair Deal yielded to the

Republican-dominated Eisenhower era, public health’s fortunes did not greatly improve. Federal support for state public health activities through PHS declined steadily after a $64 million peak in 1951 (in contrast to ballooning support for the

NIH, of course). Even though state and local funding increases partly compensated in some places, by the late 1950s there had been a slight decline in real spending per capita by health departments nationally—despite a far greater variety of activities. So public health officials found no relief for their persistent state of “fiscal malnutrition,” as Pennsylvania’s health commissioner put it in 1957.49

⬧

This was an unfavorable political and fiscal climate for multiple screening, given the enmity it tended to foster among physicians and the insufficient clinical services to take full advantage of its findings among the general population. Still, many public health researchers and health officers persisted. In a PHS survey of heart disease control activities across the country for the 1953–55 period, screening for heart disease was mentioned in twenty-two of fifty-fours states and territories, some only as a proposed activity, but in many as an ongoing project in combination with X-ray surveys for TB. Frequently these were described by the states as limited or curtailed for funding reasons. This PHS report also made the global observation that “limitation of funds and shortages of trained personnel were expressed as problems by the majority of States. The general trend to reduce governmental expenditures has not been favorable to establishing State appropriations for this new program,” and that many states were reducing their own public health budgets even as PHS grants to states were diminishing. Thus during the 1950s, with budgets shrinking in real terms and multiple screening costing something like five dollars per person (the

Massachusetts Health Department reported that its screening pilot cost more than eight dollars per person, but estimated that once routine that cost could eventually be brought as low as two dollars), and federal heart disease control grants to each state only in the tens of thousands of dollars, it is easy to see why mass screening was hard for health departments to implement on anything but a pilot basis.50

Nobody tried harder to make multiple screening work than Breslow, in his role as head of chronic disease control for the wealthy and progressive state of California.

As noted earlier Breslow in fact coined the term “multiphasic screening” in connection with the surveys he organized in several industrial plants in San Jose immediately after the war, testing employees for heart disease, lung disease, diabetes, kidney disease, and syphilis.51 As Breslow later confirmed, private physicians during the 1950s were typically hostile to the programs, regarding them as intrusive into doctor-patient relationships as well as step toward government-controlled medicine, and used their influence at the state level to suppress their practice by health departments. However multiple screening was attractive, and proved its worth, in those few “group practices” that later developed into what become known as health maintenance organizations, which had resources and incentives to follow up on findings and (unlike private physicians) were in a position to benefit from the strategy’s long-term cost-effectiveness. The Kaiser Permanente Medical Group is an example. This began in 1951 when the San Francisco Bay–based International

Longshoreman’s and Warehousemen’s Union, hearing of Breslow’s nearby pilot, asked Kaiser (which provided their prepaid health coverage) to include multiple screening under their contract. Kaiser worked with Breslow, and nearly four thousand union members were subjected to a screening panel much as in his factory study, including the same type of simplified electrocardiography and miniature chest X-rays for both lung and heart abnormalities used in Massachusetts. With vision and hearing impairments, Breslow found unsuspected high blood pressure and abnormal heartbeat especially common in this mostly middle-aged male population. Interestingly, compared with men close to “ideal weight,” those 20 percent overweight were about twice as likely to have atherosclerotic heart disease and three times as likely to have hypertension. Kaiser began offering multiple screening as part of its health insurance

plans to other clients, and by 1960 was screening twenty-five thousand patients per year. The Health Insurance Plan of Greater New York was another large group practice that later took up multiple screening, in the 1960s.52 But nationally, without a near universal system of health insurance, the conditions under which Americans would enjoy the financial and health benefits of mass multiple screening did not exist.

On the other hand, the outlook for group weight loss stood undimmed by the

1950 federal election. Here was a way for the PHS and health departments to fight heart disease without antagonizing private physicians (group participation being compatible with diet pill prescription and dietary advice), or requiring many resources, befitting an era of diminished ambitions. It was also assisted by a major

Metropolitan initiative, following closely on the election’s heels. Endorsed by both the PHS and by the AMA, Metropolitan declared a national war on “Overweight:

America’s No. 1 Health Problem”—as Louis Dublin and colleagues put it in a major address and a popular article. The address, in a feature session on obesity at the

AMA’s national meeting of mid-1951, reviewed the large body of evidence showing that the overweight and obese suffered greatly elevated mortality rates from heart disease, and especially from CHD and hypertension (understood as both a disease in itself and a probable cause of CHD). Metropolitan placed the national prevalence of overweight, defined as 10 to 19 percent above the actuarial “ideal weight” for height predicting best life expectancy, at about 15 million, and pathological obesity, defined as 20 percent above “ideal weight,” at about 5 million in a total population of 150 million. (These estimates were uncertain because based on unsystematic samples, such as recent multiple screening programs and within-company health surveys). The speaker for Dublin’s team urged the physician audience that, much as with alcoholics,

helping fat people demanded closest attention to the patient’s “personality, the social habits, the intelligence, the will-power, and capacity for self-discipline”—and of course the “emotional factors” behind overeating. In the same session, medical professor Clifford Barborka recommended “group psychiatry” especially for difficult obese patients, where they might share their “common problem . . . without fear of mockery” and eventually benefit from “mutual understanding and support.” The obesity campaign session was received with such enthusiasm that the AMA repeated it at their December 1951 West Coast meeting with a “four day feature program urging physicians to take a firmer hand with overweight patients.” At that meeting

Metropolitan increased its estimate of obesity and overweight prevalence from 20 to

30 million, more than 25 percent of the U.S. adult population.53

Supporting the Metropolitan campaign, PHS in 1951 published a brochure for health departments titled “The Greatest Problem in Preventive Medicine in the USA

Is OBESITY” (Figure 2). The brochure gave the life insurance estimates of excess mortality from diabetes, cardiovascular diseases, and cancer; it urged that people should avoid obesity to “stay healthy,” “remain attractive,” and “live and work more effectively”; and its main recommendation for public health officers was to organize weight loss groups on the grounds that these manage the “emotional disturbances” behind overeating. The PHS was also preparing detailed instructions for health departments nationally. In June 1952 the PHS Chronic Disease and Tuberculosis

Division (a precursor to the Centers for Disease Control), into which Chapman’s short-lived Chronic Disease branch had been merged, convened a conference of the researchers engaged with group weight loss studies to share experiences, and to issue consensus recommendations to encourage and inform the spreading practice. All

agreed on the centrality of emotional problems in obesity, and that groups of ten to twelve participants should meet weekly for an hour for at least several months. There was also no disagreement that the groups should be led by a physician, dietician, or similar health professional.54

Encouraged by the PHS, physicians referring their patients, and interest stirred by public health messages like Metropolitan’s “Cheers for Chubby” cartoon short, health departments nationally rolled out programs in group weight loss during the early 1950s.55 As historian Jessica Parr has recently found, they drew closely on PHS recommendations, and often offered groups in collaboration with local YWCAs. The

Boston YWCA, which had participated in the Boston Dispensary study, played a particularly influential role in designing these programs. This branch began offering its own weight control groups in late 1950, afterward supplying advice and materials to other YWCA branches nationally. Contrary to the Dispensary study conclusions that a group leader need not be a health professional, the Boston YWCA employed a psychiatrist in that role, together with a loosely psychoanalytic approach to helping participants achieve insight on why they still sought “satisfactions” mainly through eating, as in childhood.56 The branch subsidized the cost of the psychiatrist for their modestly priced program, and also provided the compulsory consultation with a nutritionist. However, according to Parr, the cost of such a medically centered program limited its uptake, and played a role in its 1956 discontinuation in Boston.

Elsewhere, health departments offered the services of the state nutritionist to help the

YWCA offer its weight control groups; in Iowa, for example, these began in 1953. In the aforementioned PHS survey of state heart disease control activities in 1953–55, nineteen of fifty-four states and territories reported offering or planning weight

control groups with PHS support (about as many as mentioning some kind of screening). The group weight loss approach caught on, although by the late 1950s direct health department programs dwindled, as autonomous groups like TOPS outstripped those led by health professionals in popularity.57

Conclusion

Group weight loss can be considered the United States’ chief health policy response, other than research, to a perceived crisis in obesity-driven heart disease during the

1950s. However, despite its popular uptake, group weight loss was no public health triumph. First, the vast majority of the hundreds of thousands who participated were women, whereas the greatest burden of heart disease was well understood to fall on men. So this approach could not have been very effective in reducing heart disease mortality, even if efficacious for weight loss. Second, the efficacy of group weight loss was dubious. Around the end of 1952 the Boston dispensary researchers conducted a follow-up analysis to see how much lasting benefit was achieved. This included 95 of the 120 participants who attended two or more sessions. Nearly half,

43 of the 95, had lost at least 10 percent of their excess weight (as calculated from their ideal weight) after one year; after two years two-thirds of this successful group still kept off at least 10 percent of the excess they had started with. So, almost one- third of those who began the program seriously and remained in contact showed significant weight loss after two years. But that optimistic conclusion was contested by researchers led by Harvard nutritionist Fred Stare, who showed that counting all participants who began the program, average weight loss was negligible after two

years, and the same as for matched controls (overweight people given nothing but a diet prescription). An influential review at the end of the 1950s still found all existing evidence for group weight loss to be poor.58 And, third, the 1950s campaign against obesity could only have promoted weight stigma—which health sociologists discovered in the 1960s and have since amply demonstrated to be harmful in itself.

Therefore we can reasonably suppose that it impaired the quality and length of life of all Americans perceived as fat, not just those who attempted group weight loss.59

Regardless of it costs and benefits, the triumph by default of group weight loss as a public health response to heart disease stands as a marker of a broader shift in public health that began in the 1950s. The type of individual-centered intervention exemplified by group weight loss, to Rutstein in 1949 an alternative to population- level “public health methods” (which for him included universal screening followed by public care, and possibly food regulation), became the standard public health approach now known as “health promotion.” It would be well for practitioners of public health today to recall the political contingency that helped cause this shift, as well as the chimeric success that can result from focus on individual behavior without intervention in the social or economic environment.

NICOLAS RASMUSSEN is Professor in History and in Environmental & Society at the University of New South Wales in Sydney. He is the author of Picture Control: The Electron Microscope and the Transformation of Biology in America, 1940–1960 (1997); On Speed: The Many Lives of Amphetamine (2008); Gene Jockeys: Life Science and the Rise of Biotech Enterprise (2014), and Fat in the Fifties: America’s First Obesity Crisis (in press).

I gratefully acknowledge support from the Australian Research Council through Discovery Project DP140101629, from Harvard and the Boston Medical

Library for a Countway Library Fellowship in History of Medicine, from the Faculty of Arts at the University of New South Wales for small travel grants, and from the

Stanford Center for Advanced Studies in Behavioral Sciences, where I was privileged to enjoy a residential fellowship in 2015 when this essay was first drafted. I am also grateful for the help of archivists at the Center for the History of Medicine at

Harvard’s Countway Medical Library, the National Archives at College Park, the

National Library of Medicine in Bethesda, the Rockefeller Archive Center, the

Truman Presidential Library, and the University of California at Los Angeles. For access to other archival materials I must also thank Mary Hilperthauser of the History

Office of the Centers for Disease Control and Prevention, Henry Blackburn of the

University of Minnesota, and Paul Sorlie, keeper of the National Heart, Lung, and

Blood Institute’s historical memory. Many individual scholars also deserve thanks for their help with and discussion of this work and their own, including David

Courtwright, Paul Griffiths, Cristin Kearns, Bob Kaplan, Howard Kushner, Michael

Lempert, Gerald Oppenheimer, Jessica Parr, Scott Podolsky, and Hans Pols

1 Stephen P. Strickland, Politics, Science, and Dread Disease: A Short History of

United States Medical Research Policy (Cambridge, Mass.: Harvard University Press,

1972); Victoria A. Harden, Inventing the NIH: Federal Biomedical Research Policy,

1887–1937 (Baltimore: Johns Hopkins University Press, 1986); Daniel M. Fox, “The

Politics of the NIH Extramural Program, 1937–1950,” J. Hist. Med. & Allied Sci. 42, no. 4 (1987): 447–66; Ronald Hamowy, Government and Public Health in America

(Northampton: Edward Elgar, 2008). NIH budget figures at http://officeofbudget.od.nih.gov/approp_hist.html. Nicolas Rasmussen, “Biomedicine and Its Historiography: A Systematic Review,” in The Historiography of Biology, ed.

Michael R. Dietrich, Mark Borrello, and Oren Harman (Dordrecht: Springer, in press).

2 Daniel J. Kevles, “The National Science Foundation and the Debate over Postwar

Research Policy, 1942–1945: A Political Interpretation of Science—The Endless

Frontier,” Isis 68, no. 1 (1977): 5–26; Daniel Lee Kleinman, “Layers of Interests,

Layers of Influence: Business and the Genesis of the National Science Foundation,”

Sci. Tech. Hum. Val. 19, no. 3 (1994): 259–82.

3 Anon., n.d., “Minutes of Meeting of the Board of Directors, Barclay Hotel, New

York City, October 18, 1945,” folder 51, box 12, papers of Paul Dudley White,

Manuscript Collection MS c36, Countway Library, Harvard Medical School

(hereafter White Papers); Rutstein to White, May 7, 1946, and attached statement by

Duckett Jones before Senate Committee on Education and Labor concerning bill S-

1606, April 26, 1946; also “Statement Presented by Dr David D Rutstein . . . at the

Hearings on H.R. 3922 Before Subcommittee on Aid to the Physically Handicapped of the U.S. House of Representative, June 7, 1946,” both in White Papers, folder 55, box 12. Bruce Fye, American Cardiology: The History of a Specialty and Its College

(Baltimore: Johns Hopkins University Press, 1996).

4 Rutstein, n.d. [1946], “Approaches to the Rheumatic Fever Problem,” folder 56, box

12, White Papers; Anon., n.d., “Minutes of the Executive Committee of the American

Council on Rheumatic Fever, April 8, 1947” and “Minutes of the Meeting of the

Executive Committee of the American Heart Association, May 4 1947,” folder 57, box 12, White Papers.

5 Fye, American Cardiology (n. 3), chap. 3; Anon., “Heart Week Drive Will Open

Today: Heavy Child Fatalities from Rheumatic Fever Stressed in Plea for Research,”

New York Times, February 8, 1948, 5; James T. Patterson, The Dread Disease:

Cancer and Modern American Culture (Cambridge, Mass.: Harvard University Press,

1987), chap. 5; Harden, Inventing the NIH (n. 1).

6 Oscar Ewing, “Wanted: Better Public Health,” Parade, May 2, 1948, 5–7; Daniel M

Fox, Power and Illness: The Failure and Future of American Health Policy

(Berkeley: University of California Press, 1993); Monte M. Poen, Harry S. Truman versus the Medical Lobby: The Genesis of Medicare (Columbia: University of

Missouri Press, 1996).

7 Dublin to Leroy Lincoln, December 2, 1947 (quote, “broader” penciled in); Dublin to Ewing to Dublin, February 8, 1945, and Dublin to Ewing, February 8, 1945; Dublin to William Shepard, March 2, 1948; all in “National Health Assembly (Corres) 1947–

49” folder, box 18, Louis Israel Dublin Papers, National Library of Medicine,

Washington, D.C. (hereafter, Dublin Papers). Alan Derickson, “‘Health for Three-

Thirds of the Nation’: Public Health Advocacy of Universal Access to Medical Care in the United States,” Am. J. Pub. Health 92, no. 2 (2002):180–91. On Dublin and

chronic disease policy, see Fox, Power and Illness (n. 6); George Weisz, Chronic

Disease in the Twentieth Century: A History (Baltimore: Johns Hopkins University

Press, 2014); Dan B. Bouk, How Our Days Became Numbered: Risk and the Rise of the Statistical Individual (Chicago: University of Chicago Press, 2015).

8 Editorial, “Mr Ewing’s Ten Year Health Program,” JAMA 138, no. 4 (1948): 297–

98; Fox, Power and Illness (n. 6); Poen, Harry S. Truman versus the Medical Lobby

(n. 6); Alan Derickson, Health Security for All: Dreams of Universal Health Care in

America (Baltimore: Johns Hopkins University Press, 2005).

9 National Heart Act of 1948, Pub. L. No. 655, available at https://history.nih.gov/research/downloads/PL80-655.pdf. For the congressional discourse, see, e.g., Second Deficiency Appropriation Bill for 1948, Hearings Before the Subcommittee of the Committee On Appropriations, U.S. Senate, 80th Cong., 2nd

Sess. H.R. 6935, An Act Making Appropriations to Supply Deficiencies in Certain

Appropriations the Fiscal Year Ending June 30, 1948, and for Other Purposes, 137–

42.

10 Fye, American Cardiology (n. 3); Oglesby Paul, Take Heart: The Life and

Prescription for Living of Dr. Paul Dudley White (Cambridge, Mass.: Harvard

University Press, 1986); J. Willis Hurst, “Paul Dudley White: The Father of American

Cardiology,” Clin. Cardiol. 14, no. 7 (1991): 62626.

11 See “Conference Structure,” in Anon., n.d. [1949], “National Conference on

Cardiovascular Diseases, January 18–20, 1950,” 3–4, White Papers, box 3 folder 67.

12 Anon., “Meeting Minutes of Proposed Heart Disease Program,” August 3, 1947, folder 24, box 50, Papers of David D. Rutstein, Manuscript Collection MS c315,

Countway Library, Harvard Medical School (hereafter Rutstein Papers); Gerald M.

Oppenheimer, “Becoming the Framingham Study 1947–1950,” Amer. J. Pub. Health

95, no. 4 (2005): 602–10.

13 Anon. [Ogelsby Paul?], “Interview with David Rutstein,” September 17, 1984, folder 41, box 84, White Papers; Anon., “Meeting Minutes of Proposed Heart Disease

Program” (n. 12); Anon., “Proposed Study of the Epidemiology of Cardiovascular

Disease,” n.d. [1947?], folder 24, box 50, Rutstein Papers; Francis Weber,

“Community-Wide Chest X-Ray Surveys: I. An Introduction to the Problem,” Pub.

Health Rep. 62, no. 18 (1947): 652–58.

14 Boone to E. R. Coffey, September 5, 1947; Boone to Meadors, September 5, 1947;

L. C. Robbins to Meadors, September 5, 1947; all in temporal folders, Framingham

Study Historical Papers, National Heart, Lung, and Blood Institute (NHLBI),

Bethesda Md. (hereafter Framingham Papers). Getting to Rutstein, September 24,

1947, and Rutstein to Donald Armstrong, September 26, 1947, both in folder 24, box

50, Rutstein Papers. On the Framingham tuberculosis demonstration, see Ralph C

Matson, “The Framingham Health and Tuberculosis Demonstration. 1: Community

Prevention, Control, and Treatment of Diseases, as Carried Out at Framingham,

Massachusetts, USA,” Lancet 203, no. 5259 (1924): 1243–44, and Diane Hamilton,

“Research and Reform: Community Nursing and the Framingham Tuberculosis

Project, 1914–1923,” Nursing Res. 41, no. 1 (1992): 8–13.

15 J. A. Crabtree to Rutstein, September 30, 1947, and Rutstein to Thomas Parran,

October 10, 1947, both in folder 24, box 50, Rutstein Papers. Robbins to Boone,

October 22, 1947 (“eggs”), Boone to Getting, December 10, 1947, both in temporal folders, Framingham Papers. In December 1947 Meadors was reported as leading the

“Heart Disease Epidemiology” study and Robbins the “Cardiovascular Hygiene

Demonstration.” Meadors, “Report of Activities for the Month of December 1947,”

January 8, 1948, folder 24, box 50, Rutstein Papers; Meadors to Office of Surgeon

General, July 20, 1948 (“alienating”), Framingham Papers; Anon., n.d. [1947], “Heart

Disease Epidemiology Study” including “Agreement on Administrative

Arrangements for Fiscal Year 1948,” folder 24, box 50, Rutstein Papers.

16 Boone to Getting, December 10, 1947, folder 24, box 50, Rutstein Papers;

Oppenheimer, “Becoming the Framingham Study” (n. 12); Robert A. Aronowitz,

“The Framingham Heart Study and the Emergence of the Risk Factor Approach to

Coronary Heart Disease, 1947–1970,” Revue d’histoire des sciences 64, no. 2 (2011):

263–95; Élodie Giroux, “The Framingham Study and the Constitution of a Restrictive

Concept of Risk Factor,” Soc. Hist. Med. 26, no. 1 (2013): 94–112.

17 Massachusetts Department of Public Health Press Release, June 10, 1948, folder

23, box 50, Rutstein Papers; Anon., “Outline of the Proposed Work and the Plan of

Attack of the Heart Control Program,” n.d. (hand marked as September 3,1948), L. C.

Robbins to Rutstein, September 16, 1948, both in folder 25, box 46, Rutstein Papers.

George F. Bowers et al., “Proposed Endorsement of Heart Demonstration Program by

Newton Medical Club,” October 8, 1948, folder 38, box 50, Rutstein Papers. On the

Massachusetts cancer program, see Fox, Power and Illness (n. 6), 46, passim, and 43

George H. Bigelow and Herbert L. Lombard, “Experience with the Program of

Cancer Control in Massachusetts,” Am. J. Pub. Health 18, no. 4 (1928): 413–20.

18 See, e.g., W. Palmer Dearing and Alexander E. Turner, “Chest Fluorography with

Portable X-ray Equipment on 35 mm. Film,” Pub. Health Rep. 55, no. 52 (1940):

2369–77; William Roemmich et al. “Preliminary Report on a Community-Wide Chest

X-ray Survey at Minneapolis, Minnesota,” Pub. Health Rep. 63, no. 40 (1948): 1285–

90.

19 Lester Breslow, “Multiphasic Screening Examinations—An Extension of the Mass

Screening Technique,” Amer. J. Pub. Health 40, no. 3 (1950): 274–78, quotations on

278; A. L. Chapman, “The Concept of Multiphasic Screening,” Pub. Health Rep. 64, no. 42 (1949): 1311–14, esp. 1314; Anon., “General Staff Meeting Minutes,” January

27, 1950, folder 20, box 2, NIH Directors’ Files, Manuscript Collection 536, U.S.

National Library of Medicine, Bethesda, Md.

20 Lester Breslow, “An Historical Review of Multiphasic Screening,” Prevent. Med.

2, no. 2 (1973): 177–96.

21 Getting and Lombard, “The Evaluation of Pilot Clinics, Mass Screening or Health

Protection Programs,” n.d. [stamped as received June 12, 1952], folder 37, box 68,

Rutstein Papers.

22 Lester Breslow, “Multiphasic Screening in California,” J. Chron. Dis. 2, no. 4

(1955): 375–83, quotation on 382; Breslow, “Historical Review” (n. 20).

23 David D. Rutstein, Charles R. Williamson, and Felix E. Moore, “Heart Disease 44

Case Finding by Means of 70 Millimeter Photofluorographic Films,” Circulation 4, no. 5 (1951): 641–51; David D. Rutstein with Ernest Craige (illust.), “Screening Tests in mass surveys and Their Use in Heart Disease Case Finding,” Circulation 4, no. 5

(1951): 659–65.

24 Rutstein, “Approaches to the Rheumatic Fever Problem,” n.d. [1946?], folder 56, box 12, White Papers; Howard Sprague, “Summary Statement, Committee 1, Section

1,” n.d. [January 1950], 3, folder 60-1, box 3, White Papers.

25 Egon Kattwinkel, Vlado Getting, Ernest Morris, Herbert Lombard, and Lewis

Robbins, “A Public Health Heart Program—First Report,” May 24, 1949; Pearl

Thoreson, “Minutes of the Third Meeting of the Subcommittee on Nutrition,” May 6,

1949; both in folder 31, box 50, Rutstein Papers.

26 Dublin Memoirs, chap. 6, folder “Memoirs (Chapters 1–10),” box 7, Dublin Papers.

See Association of Life Insurance Medical Directors and Actuarial Society of

America, The Medico-Actuarial Mortality Investigation, vol. 1 (New York: Actuarial

Society, 1912); Actuarial Society of America and the Association of Life Insurance

Medical Directors, Medical Impairment Study (New York, Actuarial Society, 1929 and 1931); Emma Seifrit Weigley, “Average? Ideal? Desirable? A Brief Overview of

Height-Weight Tables in the United States,” J. Amer. Diet. Assoc. 84, no. 4 (1984):

417–23. Also see Bouk, How Our Days Became Numbered (n. 7).

27 Louis I. Dublin with Herbert H. Marks, “The Influence of Weight on Certain

Causes of Death,” Hum. Biol. 2, no. 2 (1930): 159–84; Herbert H. Marks, “Body

Weight: Facts from Life Insurance Records,” Hum. Biol. 28, no. 2 (1956): 217–31. 45

28 Thoreson, “Minutes of the Third Meeting” (n. 25); Nicolas Rasmussen, “Weight

Stigma, Addiction Science, and the Medication of Fatness in Mid-20th Century

America,” Soc. Health Illness 34, no. 6 (2012): 880–95; Laura Dawes, Childhood

Obesity in America: Biography of an Epidemic (Cambridge, Mass.: Harvard

University Press, 2014).

29 Percy L. Smith, “Alcoholics Anonymous,” Psychiatric Quart. 15, no. 3 (1941):

554–62; Harry M. Tiebout, “Therapeutic Mechanisms of Alcoholics Anonymous,”

Amer. J. Psychiatry 100, no. 4 (1944): 468–73; Robert Heath, “Group Therapy,”

Psychosom. Med. 8, no. 2 (1946): 118; L. Erwin Wexberg, “Outpatient Treatment of

Alcoholics,” Amer. J. Psychiatry 104, no. 9 (1948): 569–72; William W., “The

Society of Alcoholics Anonymous,” Amer. J. Psychiatry 105, no. 5 (1949): 370–75.

See also William L. White, Slaying the Dragon: The History of Addiction Treatment and Recovery in America (Bloomington, Ill.: Chestnut Health Systems/Lighthouse

Institute, 1998) and Mariana Valverde, Diseases of the Will: Alcohol and the

Dilemmas of Freedom (Cambridge: Cambridge University Press, 1998).

30 Getting to Rutstein, February 21, 1949, folder 25, box 46, Rutstein Papers; P. A.

Thoreson, “Minutes of the Third Meeting” (n. 25), Arthur Baldwin and Pearl

Thoreson, “Conclusions,” May 10, 1949, Anon., “Newton Heart Demonstration

Program, a Summary of Activities,” November 8, 1950, all in folder 31, box 50,

Rutstein Papers.

31 Thoreson, “Minutes of the Third Meeting” (n. 25); Kattwinkel et al., “Public Health

Heart Program” (n 25); Rutstein, n.d., “Heart Disease Programs, Clinical Basis and

Organizational Aspects, Modified from a Manuscript Prepared for Publication in

Administrative Medicine, edited by Haven Emerson, New York: Thomas Nelson and

Sons, 1949,” folder 15, box 73, Rutstein Papers; American Medical Association

Council on Foods and Nutrition, “Some Nutritional Aspects of Sugar, Candy, and

Sweetened Carbonated Beverages,” JAMA 120, no. 10 (1942): 763–65. Many thanks to Cristin Kearns for this last reference.

32 A. L. Chapman, “Weight Control—A Simplified Concept,” Pub. Health Rep. 66, no. 23 (1951): 725–31; Marjorie Grant and Joseph Rosenthal, “Group Psychotherapy for Weight Control Delivery,” Mass. Health J. 31 (May 1950): 8–9. Benjamin

Kotkov, “Experiences in Group Psychotherapy with the Obese,” Psychosom. Med. 15, no. 3 (1953): 243–51.

33 Charles T. Ambrose, “Joseph Hersey Pratt (1872–1956): An Early Proponent of

Cognitive-Behavioral Therapy in America,” J. Med. Biog. 22, no. 1 (2013): 35–46, quotation on 38.

34 Ben Shepherd, A War of Nerves: Soldiers and Psychiatrists 1914–1994 (London:

Jonathan Cape, 2000); Saul Scheidlinger, “The Group Psychotherapy Movement at the Millennium: Some Historical Perspectives,” Int. J. Group Psychother. 50, no. 3

(2000): 315–39; Benjamin Kotkov, “Technique and Explanatory Concepts of Short-

Term Group Psychotherapy,” J. Psychol. 28, no. 2 (1949): 369–81.

35 Kotkov, “Experiences in Group Psychotherapy” (n. 32), 243–44 (“loneliness,” etc.);

Scheidlinger, “Group Psychotherapy Movement” (n. 34), 319 (“in a group”); Kotkov,

“Technique and Explanatory Concepts” (n. 34), 377 (“permissive”). 47

36 Anon., “‘Appetites Anonymous’ Urged for Fat People,” Los Angeles Times, May 5,

1950, 1; Antoinette Donnelly, “Fatties Anonymous: A New Way to Reduce,”

Chicago Tribune, October 12, 1950, C1; Jessica M. Parr, “Obesity and the Emergence of Mutual Aid Groups for Weight Loss in the Post-war United States,” Soc. Hist.

Med. 27, no. 4 (2014): 768–88.

37 Alexander Langmuir, n.d. [January 1950], report “VI-a 18,” “Epidemiology,” folder 65, box 3, White Papers, 2.

38 W. A. Brumfield, “Final Report, Community Services, Case Finding and

Epidemiology,” January 19, 1950, folder 68, box 3, White Papers, 1.

39 Hirschel Nisonger, n.d. (January 1950), “Suggested Problems for Consideration by the Committee on Lay Education and Prevention, Section on Community Services,”

2, folder 66, box 3, White Papers; Irving Wright, Lyman Duff, and Forrest Kendall,

January 19, 1950, “Suggestions from Section 1 for Sections 2 and 3 Consideration,” folder 60, box 3, White Papers.

40 Report by A. L. Chapman, 5–10 in “Meeting of the National Advisory Heart

Council Agenda and Minutes,” June 7–8, 1949, cabinet: C, file: Meeting Minutes

June 7–8, 1949, and report by F. Gillick, Meeting of the National Advisory Heart

Council Agenda and Minutes, June 1–3, 1950, cabinet: C, file: Meeting Minutes June

1–3, 1950; both in Henry Blackburn Private Collection, University of Minnesota,

Twin Cities (hereafter Blackburn Collection).

41 Anon., “Association News,” Amer. J. Pub. Health 40 (1950): 1192; Anon.

[Chapman?], PHS Heart Disease Control Branch, Division of Chronic Disease,

“Report of Heart Disease Control Activities for Fiscal Year 1950,” n.d. [1950], folder

38, box 50, Rutstein Papers; C. L. Mache Jr., “The Charleston Heart Demonstration

Program; A Preliminary Report,” J. S.C. Med. Assoc. 49, no. 10 (1953): 268–69.

42 Report by A. L. Chapman in “Meeting of the National Advisory Heart Council

Agenda and Minutes, 24–25 October 1950,” 14–20, in cabinet: C, file: Meeting

Minutes October 24–25, 1950, Blackburn Collection.

43 Jones to Rutstein, November 3, 1948; Anon., “Minutes of Meeting, Committee on

Cardiovascular Disease Control,” November 12, 1948; Committee on Cardiovascular

Disease Control, memo to the National Advisory Heart Council, December 1, 1948, all in folder 38, box 50, Rutstein Papers.

44 Rutstein to W. Palmer Dearing, August 23, 1950, folder 36, box 50, Rutstein

Papers; David D. Rutstein and Ernest Craige, “Screening Tests in Mass Surveys and

Their Use in Heart Disease Case Finding,” Circulation 4, no. 5 (1951): 659–65.

45 White memo to “National Advisory Heart Council,” October 24, 1950, and associated untitled action plan; PHS brochure “Multiple Screening,” n.d. [1951], GPO

83-171133, Public Health Service Publication 7; both in folder 35, box 50, Rutstein

Papers.

46 U.S. Public Health Service (PHS), Bureau of State Services, State Heart Disease

Control Programs: Selected Information Included in the State Public Health Plans

Submitted by State Health Departments for Fiscal Years 1954 and 1955, PHS pub. no. 406 (Washington, D.C.: GPO, May 1954).

47 Republican National Committee, n.d. [1950?], “Part 1: The 26th Pennsylvania

Congressional Election”; and Republican National Committee, n.d. [1950?], p.1;

Mike Gorman to Donald Dawson, n.d. [March 1951]; Dawson to Gorman, April 3,

1951; all in folder 1, box, 575, OF 103, Papers of Harry S. Truman, Truman

Presidential Library and Museum, Independence Mo.; Anon., “Voters’ Verdict,”

Washington Post, November 9, 1950, 12; Derickson, Health Security for All (n. 8);

Poen, Harry S. Truman versus the Medical Lobby (n. 6), chaps. 6–7.

48 William Shepard, “Public Health and “Socialized Medicine,” Amer. J. Pub. Health

41, no. 11, pt. 1 (1951): 1333–41, quotations on 1335, 1337–38.

49 Barkev Sanders, “Local Health Departments: Growth or Illusion?,” Pub. Health

Rep. 74, no. 1 (1959): 13–20; Berwyn Mattison, “Financing,” Amer. J. Pub. Health

47, no. 11, pt. 2 (1957): 20–21, quotation on 21.

50 U.S. Public Health Service, State Heart Disease Control Programs (n. 46), 2;

Getting and Lombard, “The Evaluation of Pilot Clinics, the Mass Screening or Health

Protection Programs,” June 1952, folder 37, box 68, Rutstein Papers.

51 C. Kelly Canelo, Dwight M. Bissell, Herbert Abrams, and Lester Breslow, “A

Multiphasic Screening Survey in San Jose,” Calif. Med. 71, no. 6 (1949): 409–13;

Breslow, “Multiphasic Screening Examinations” (n. 19).

52 Breslow, “Historical Review” (n. 20); E. Richard Weinerman, Lester Breslow, 50

Nedra B. Belloc, Anne Waybur, and Benno K. Milmore, “Multiphasic Screening of

Longshoremen with Organized Medical Follow-Up,” Amer. J. Pub. Health 42 (1952):

1552–67; Sam Shapiro, “Evaluation of Two Contrasting Types of Screening

Programs,” Prevent. Med. 2, no. 2 (1973): 266–77.

53 Louis Dublin, “Overweight: America’s No. 1 Health Problem,” Today’s Health,

September 1952, 18–21; Louis Dublin and Herbert Marks, “Mortality among Insured

Overweights in Recent Years,” Trans. Life Insurance Med. Directors Amer. 35

(1951): 235–63; Clifford Barborka, “Present Status of Obesity Problem,” JAMA 147, no. 11 (1951): 1015–19, quotation on 1016; Anon., “Unneeded Fat Hangs Heavy on

1/4 of U.S.,” Chicago Tribune, December 5, 1951, 1.

54 Anon., “The Greatest Problem in Preventive Medicine in the USA Is OBESITY,”

U.S. Public Health Service Publication 6, GPO 171156, n.d. [1951], 5; Malcolm J.

Ford, “The Group Approach to Weight Control,” Amer. J. Pub. Health 43 (1953):

997–1000.

55 “Cheers for Chubby,” 1951 Metropolitan Life Insurance Company, Jerry Fairbanks

Prod., https://www.youtube.com/watch?v=14oSJAYFMwo.

56 Martha E. Gentry and Florence L. Swanson, “A Psychological Approach to Weight

Control,” Amer. J. Nursing 52, no. 7 (1952): 849–50, quotation on 849; Jessica Parr,

“Obesity and Mutual Aid in the Postwar United States: From Public Health to Weight

Watchers” (Ph.D. thesis, University of New South Wales, 2017), chap. 3.

57 Parr, “Obesity and Mutual Aid” (n. 56); PHS, State Heart Disease Control

Programs (n. 46).

58 Arnold Kurlander, “Group Therapy in Reducing: Two-Year Follow-Up of Boston

Pilot Study,” J. Amer. Diet. Assoc. 29, no. 4 (1953): 337–39; L. Bowser, M. Trulson,

R. Bowling, and F. Stare, “Methods of Reducing: Group Therapy vs. Individual

Clinic Interview,” J. Amer. Diet. Assoc. 29, no. 12 (1953): 1193–96; Albert Stunkard and Mavis McLaren-Hume, “The Results of Treatment for Obesity: A Review of the

Literature and Report of a Series,” Arch. Intern. Med. 103, no.1 (1959): 79–85.

59 Rasmussen, “Weight Stigma” (n. 28); Claudia Sikorski, Melanie Luppa, Marie

Kaiser, Heide Glaesmer, Georg Schomerus, Hans-Helmut König, and Steffi Riedel-

Heller, “The Stigma of Obesity in the General Public and Its Implications for Public

Health—A Systematic Review,” BMC Pub. Health 11, no. 661 (2011): 1–8.