Draining this poison from our trillion-dollar food system is not going to happen quickly or easily. Every link in the chain, from factory farms to school lunches, is dominated by a Mars or a Monsanto or a McDonald’s, each working tirelessly to lower its costs and raise its profits. But that’s still no reason to despair. There’s a lot we can do right now to improve fat people’s lives—to shift our focus for the first time from weight to health and from shame to support.

The place to start is at the doctor’s office. The central failure of the medical system when it comes to obesity is that it treats every patient exactly the same: If you’re fat, lose some weight. If you’re skinny, keep up the good work. Stephanie Sogg, a psychologist at the Mass General Weight Center, tells me she has clients who start eating compulsively after a sexual assault, others who starve themselves all day before bingeing on the commute home and others who eat 1,000 calories a day, work out five times a week and still insist that they’re fat because they “have no willpower.”

Acknowledging the infinite complexity of each person’s relationship to food, exercise and body image is at the center of her treatment, not a footnote to it. “Eighty percent of my patients cry in the first appointment,” Sogg says. “For something as emotional as weight, you have to listen for a long time before you give any advice. Telling someone, 'Lay off the cheeseburgers' is never going to work if you don't know what those cheeseburgers are doing for them.”

The medical benefits of this approach—being nicer to her patients than they are to themselves, is how Sogg describes it—are unimpeachable. In 2017, the U.S. Preventive Services Task Force, the expert panel that decides which treatments should be offered for free under Obamacare, found that the decisive factor in obesity care was not the diet patients went on, but how much attention and support they received while they were on it. Participants who got more than 12 sessions with a dietician saw significant reductions in their rates of prediabetes and cardiovascular risk. Those who got less personalized care showed almost no improvement at all.

Still, despite the Task Force’s explicit recommendation of “intensive, multicomponent behavioral counseling” for higher-weight patients, the vast majority of insurance companies and state health care programs define this term to mean just a session or two—exactly the superficial approach that years of research says won’t work. “Health plans refuse to treat this as anything other than a personal problem,” says Chris Gallagher, a policy consultant at the Obesity Action Coalition.

The same scurvy-ish negligence shows up at every level of government. From marketing rules to antitrust regulations to international trade agreements, U.S. policy has created a food system that excels at producing flour, sugar and oil but struggles to deliver nutrients at anywhere near the same scale. The United States spends $1.5 billion on nutrition research every year compared to around $60 billion on drug research. Just 4 percent of agricultural subsidies go to fruits and vegetables. No wonder that the healthiest foods can cost up to eight times more, calorie for calorie, than the unhealthiest—or that the gap gets wider every year.