We as a culture need to stop focussing on obesity as a primary cause of bad health – and not just out of compassion but for pragmatic reasons too.
There have been a few articles in the past few days (notably on the BBC and in the Guardian) citing a new study, editorialised in the British Journal of Sports Medicine, indicating that exercise is bugger-all use for losing weight, and that really it’s all about diet.
This may or may not be the case – to be fair to the research, they were really attacking bad diets and in particular sugary drinks more than dismissing exercise, and the news headlines are largely spin, but what I want to argue is that focussing on ‘obesity’ as the monster to beat rather than bad health is in and of itself incredibly damaging. So, for all you viewing at home…
*Stares intently into camera 1*
I have arguments about social and media attitudes toward obesity a lot, because I think they’re terrible, and these articles are an example of it. I think generally that what’s being argued for by your ‘Health At Every Size‘ or ‘fat-positive’ folk is not that fat is in itself good – or bad or whatever else. Its thrust is that the focus on this one physical, visible manifestation for ill health is wrongheaded and unhelpful. It’s wrongheaded and unhelpful for several reasons.
Reason 1: #notallfatties
Not every fat person is unfit or has bad health markers relating to their fatness. Over the studies I’ve cited here and others I’ve looked at comparing ‘metabolically healthy’ obese people with obese people with markers for bad health (high blood sugar, blood pressure and cholesterol, or a higher level of ‘visceral’ or gut fat), the number of ‘healthy’ obese people varies between 20% and 50%.
Of course, that’s not saying that everyone who is obese and healthy stays that way. One study began with a group of 181 obese people, 66 (36%) of whom were considered metabolically healthy and found that by the end of a 20 year period, 38% of them were still considered healthy. Around half had become unhealthy during that period and others were eliminated for other reasons (such as losing weight). This gives us a ‘genuinely healthy over time’ rate of about 14%.
There are two factors to consider here. Firstly, as we’ll see later in this article, studies that don’t control for lifestyle factors such as diet and physical activity are not presenting a true picture of the link between obesity itself and bad health. Secondly, assuming this 14% longer term figure is accurate, that’s still more than one fat person out of every ten you meet who is doing – and will continue to do – just fine, health-wise, at their current weight. Overall, that’s not an insignificant number of people. Anyway, all that being said…
Reason 2: When did we agree that thin = healthy?
‘Normal’ weight is not a good predictor for physical health and fitness. In fact as the editorial I referenced in my first paragraph observes: “the obesity epidemic represents only the tip of a much larger iceberg of the adverse health consequences of poor diet… Up to 40% of those with a normal body mass index will harbour metabolic abnormalities typically associated with obesity, which include hypertension, dyslipidaemia, non-alcoholic fatty liver disease and cardiovascular disease.”
Up to 40%, you guys. By focussing on obesity as the problem to solve we are letting down 40% of ‘normal’ weight people. Those BBC and Guardian articles I linked at the start of this are wilfully ignoring the fact that almost half of normal weight people – who don’t ‘need’ to lose weight at all – are in the same sort of bad health as that associated with obesity. Even if the percentage of obese people facing those metabolic issues is higher – and I would expect that it’s considerably higher, don’t get me wrong – that’s still a LOT of folk who’re getting a free pass on being pressured/encouraged (obviously I favour the latter) to live well simply because the outcomes of their bad lifestyles are not visible – still very much there, just not manifested along with fat on their bodies. That’s really not good.
Could it be that (whisper it) obesity is not actually causal factor in all of these cases but rather a correlator with the same root cause? Up to 40% of normal-BMI people having obesity-associated health markers says to me that it’s worth considering the extent to which these markers are caused by obesity, versus the extent to which obesity is caused by the same thing as the health indicators.
A study from a Canadian research institute on metabolically healthy and unhealthy people, normal weight, overweight and obese, did find that over a ten year period the risk of metabolically healthy obese people for cardiac disease or death was 24% higher than that of metabolically healthy people of normal weight. However, this study has been criticised for failing to account in any way for the physical activity of the participants.
Another study from researchers at Middle Tennessee State University on physical fitness found that fitness, not weight, predicted the likelihood of the participants dying in the study’s intervening (7.7 to 16) years. Indeed it found that thin, unfit people had twice the mortality risk of obese fit people, and that obese fit people had similar mortality rates to normal weight fit people.
Caveat: I am well aware that some health problems are directly caused by obesity, such as joint strain. Others are linked to specific sorts of obesity. For example, a lot of gut fat around your organs (usually seen on blokes as a paunch, though women’s fat distribution tends to shift in this direction as they age) is a much more dangerous way to carry your weight than, say, on your hips – indeed, in a world-gone-topsy-turvy sort of way, research presented in Munich in 2012 found that normal weight people with this ‘central obesity’ gut fat were actually at greater risk of death than not only obese people with a healthy waist-to-hip ratio but even obese people who carried their fat around their gut, suggesting that where you carry your weight is far more important than how much of it you carry.
I have also acknowledged (in point 1) that the percentage of obese people with said ‘metabolic issues’ is most certainly higher than 40%, because bad food and not enough exercise does cause obesity in a lot of people – no one is denying that – and bad food and not enough exercise also causes bad health. What I’m suggesting is that the relationship is not so cut-and-dried that it justifies the trend of using obesity as a one-stop-shop indicator for bad health and a bad lifestyle.
Reason 3: Shaming fatties will not help them lose weight
Even if we agree that weight loss is a good aim to have generally, it has been shown, over and over again, that the media and society in general’s ‘shame’ approach to weight loss is not only cruel but actively counter-productive, driving many fat people to a depression that worsens their chances of being healthier, whether as the weight they are or lighter. It encourages comfort eating and hibernation, and unreasonable standards for beauty and body shape make people feel self-conscious and humiliated if they do venture out to exercise. You know the drill.
Yes, I’m sure there are individuals for whom ‘shaming’ works. They are the minority. I’m sure they can shame themselves just fine without the help of the media and society at large. Everyone else would get on a lot better without the constant focus on their weight rather than on health and fitness outcomes.
Reason 4: Why not fight the war we can win?
Sustained, permanent weight loss is very difficult, and whether you can do it, in general, has at least as much to do with your genes as any amount of willpower. The much-used ‘95% of dieters regain all the weight’ figure seems to be a myth, as there is no consistent data showing how many people keep off the weight they lose – though it is almost certainly under half. However, studies do consistently show that your body’s metabolism will do its damnedest to get you back to your peak weight, and that makes keeping weight off not just the work of a few months’ or years’ effort, but a daily act of willpower, ignoring the signals being given to you by your own body, for the rest of your life.
Mock or demonise these folk as much as you like (wait, no, don’t, that’s the point of this article) but looking at this pragmatically we need to accept that the majority of these folk are doomed to failure. What it comes down to is that it doesn’t actually matter whether losing weight is itself a desirable goal over and above ‘get fit’ or ‘eat well’. Most people can’t do it. Most people will never keep that weight off.
Further to this, weight fluctuation itself is linked with cardiac disease, suggesting that by pushing weight loss as the ultimate goal for promoting fitness, given that we know that most people who lose weight will gain it again, could be actively increasing dieters’ risk of illness and early death.
But permanent lifestyle changes will have positive health effects – for the individual – regardless of whether they’re successful in losing weight (and even if losing weight over and above would be ideal, or better). That is true whether they change their diet, their physical activity, or both. And across a population, those people turn from healthier individuals into useful population-wide statistics on health outcomes.
Not that we’ll see those statistics on other health markers. Because instead, we’re focussing on the statistic of obesity itself as a catch-all single indicator for lifestyle-induced bad health. Even though (did I mention?) up to 40% of BMI-normal people are in similarly bad health.
So that’s why I get pissed off when it’s argued that movements pushing for us to stop focussing on weight loss and BMI and start focussing on permanent lifestyle improvements are in some way unproductive, and why I’m annoyed by the resulting concern trolling, or worse the ‘PC gone mad’ claims that fatties are trying to ‘normalise’ their giant bodies, and even that HAES and fat-positive activists are dangerous.
Again, nobody is saying that physical activity and good food aren’t good things. They are vital things. No one is saying that anyone should relax, put down the treadmill (you lift treadmills, right?) and pick up a burger. But we need to be talking about eating better and moving more to improve health outcomes for everybody, and we need to stop scapegoating the people who happen to have physically manifested a visible correlator for the negative health outcomes caused by such lifestyles. We are doing everybody, including thin people, a disservice in the process.