Sadly, I also think it’s wrong.
Why is it wrong?
Because, first of all, weight isn’t equivalent to health. And therefore, weight loss isn’t equivalent to automatically improving health. But I think we all know that.
More complicatedly, weight isn’t even the most important factor in determining a person’s health. And this is an idea that I think might encounter some resistance. But I’m totally serious.
(And I’m sorry if this is all a little too “Public Health 101” for everyone, but bear with me. All that theoretical crap I learned in school actually DOES, it turns out, have relevance.)
I propose that the insistence on “obesity” as a personal failing, and even the conceptualization of “obesity” as a disease, is actually an artifact of an individualist perspective of health. Which is to say, because we tend to believe (as Americans, as North Americans, and sometimes just as humans) that health is an individual issue, not a social or public one, we revert to blaming individuals for all kinds of conditions and illnesses that do not jibe with our cultural ideals of What A Person Should Be.
But if you start to look at health as more than just a personal balance sheet of good behaviours vs. bad behaviours, and even look beyond genetic underpinnings, or plain roll-of-the-dice random luck, you’ll see that there are broad, societal patterns of who gets sick and who stays well. And thus, we run smack-dab into the concept of Social Determinants of Health.
If fat people experience poorer health than other people — and there are stacks of epidemiological associations that imply we do, the lower mortality risk of “overweight” people notwithstanding — then maybe it would be useful to put down the keys to the blame-mobile for just a moment and consider one question:
Why?
Now, if “obesity” were one of those things that had a single cause, and a single mechanism, and, subsequently, a single, reliable cure — then maybe it would be fair to jump instantly to the conclusion that being fat, itself, is the problem. (And, naturally, losing weight would be the magic-bullet cure.)
Except it doesn’t work that way.
At present, we’ve got so many hypotheses for why people get fat that you could drive yourself crazy trying to read it all. There’s, you know, adenoviruses, and some kind of woo-woo social transmission by which your being fat tacitly encourages your friends to get fat, and there’s the leptin-deficiency hypothesis which turned out not to apply as easily to humans as it did to specially-bred mice, and the whole food addiction thing, the obesogenic environment thing, the evil-carbohydrates thing, and then the genetic component (which, in itself, seems to implicate so many different genes that I don’t think you’d be able to find a police station long enough to accommodate a line-up.)
Fatness, it turns out, is a many-splendoured thing.
And, as a result, we’ve never found that wonderful magic-bullet cure I mentioned, even though people will swear up and down on their life, on their Bibles, on their mother’s-mother’s-mother’s grave, that we have.
In that case, I have only to ask: then why are so many of us — most of whom desperately don’t want to be — still fat?
Because there isn’t a single “Cure.” Because there isn’t a single cause or mechanism. And, not least of all, because fatness isn’t a disease.
A quote I love:
My definition of a disease is a categorization…that has predictive power and, in some cases, enables causal inferences to be made. There remains the difficult but not insoluble problem of distinguishing disease from social deviance.
-Ian R. McWhinney, CMAJ, VOL. 136, APRIL 15, 1987
I’m preeeeetty sure that the whole OMGBESITY CRISIS!!!! is actually more about policing social deviance than it is about concern for our health.
And even if fat people are at higher risk for certain diseases, I still contend that fatness itself isn’t the problem.
So what is?
I posit that the problem is social inequity. To wit: marginalized people have poorer health outcomes.
Are fat people marginalized? You betcha.
Does it affect our health? Quite possibly.
As always, let’s hash it all out in comments.
Comments
35 responses to “Are fat people unhealthy? (part 2)”
I agree, but I don’t think that’s even the only reason! Several other explanations come to mind:
– A history of yo-yo dieting might contribute to poor health.
– Some diseases cause weight gain, and anybody who’s already sick might be more likely to get other things on top. (Never mind the inevitable chicken-and-egg problem with diabetes.)
– Many medications for psychological conditions cause weight gain as well, and mental health problems increase your risk of getting sick.
In that case, I have only to ask: then why are so many of us — most of whom desperately don’t want to be — still fat?
Bad question. Any troll could tell you that it’s because not wanting something doesn’t equal having the will power to will it away, silly! ;)
Tiana –
Those other reasons you mention are spot-on, I think. There’s definitely more than one factor leading to the correlation.
As for not having willpower — yeah. That argument basically stems from what I see as a “pessimistic assumption about human nature.” Which is something I fundamentally disagree with. People can believe that all they want — doesn’t make it true. You’d think with the amount of desperation there is among the general population to lose weight, that SOMEONE, SOMEWHERE would have come up with a better solution than we currently have. But, no.
Hi Michelle – great post. I totally agree with you that fat does not necessarily equal unhealthy. Take me for instance – I am obese, and yet I have none of the health problems usually associated with obesity, such as diabetes, heart problems or high blood pressure. I choose to eat well and I exercise, but I’m still fat – clearly, being fat doesn’t mean as much as the media would have us believe.
Here in Australia some fast food outlets raise their meal prices in lower socio-economic areas. Those are the same areas that have the highest density of fast food restaurants. Where I live, on the other hand, you have to travel to another suburb if you want fast food, and there are exclusive parts of Sydney where there are no fast food outlets at all.
To me this indicates that health has not much to do with what size you are, and more to do with the choice that comes with privilege.
Kelly –
To me this indicates that health has not much to do with what size you are, and more to do with the choice that comes with privilege.
EXACTLY. In lots of cases, this is totally true. And it’s often ignored, especially (it seems to me) by Americans, because of our whole “rugged individualist” mindset. We like to believe that people have all-powerful free will, and hate to think there are societal forces limiting people’s free will. But turning a blind eye to those forces doesn’t make them go away — it just makes us blame people for shit that isn’t their fault, and allows us to feel comfortable in our privilege.
It’s essentially the Fundamental Attribution Error in disguise — if I’m doing well, it’s because of my own efforts. If someone else is less well off, well — that’s their fault, by virtue of being lazy, lacking willpower, etc.
I think stress is a very likely culprit for both increased health issues and for a significant amount of the obesity out there. Just being “marginalized” doesn’t seem enough, since gay and lesbian people are not, as far as I’ve ever heard, less healthy than the general population.
Lots of people eat due to stress, or eat less healthy food because life is too busy and stressful to take the extra time it requires to obtain and prepare healthy food when less healthy food is so readily available. Same goes for not doing much exercise. Then a poor diet and lack of exercise wind up making you less able to cope with stress factors and vicious circle ensues.
Poverty undoubtedly has health factors connected with just being marginalized, but also resuls in difficulty in obtaining and preparing healthy food and fitting in exercise.
But I suspect “stress” is as overused and misunderstood a term as “obesity”. We really haven’t completely passed the spirits and humours approach to medicine yet.
Well, the thing is, I think the marginalization leads to the stress which leads to the health outcomes. That is Muennig’s (last link) theory, at any rate. Also add to the mix that marginalized people have poorer access to health care, or are perhaps treated worse by healthcare providers that they do access.
I have to check into the sexual identity marginalization health link thing, but I would suspect that there is a link there, if not a well-publicized one.
Stress might be overused and misunderstood, for sure. It has become kind of a catch-all. But Selye’s General Adaptation Syndrome at least gives a basic account of what people are trying to get at when they talk about “stress.”
Bravo!
Complex thoughts conveyed beautifully.
On the “unified theory of fatness” front, I keep meaning to share this link with you:
http://www.cdc.gov/pcd/issues/2009/jul/09_0013.htm
The whole issue of Chronic Disease Prevention is (oy) on obesity and it needs serious, serious deconstruction. I actually laughed out loud at some of the articles.
You rule, though.
WRT2 – thanks for the link. Definitely checking it out. I know that chronic disease prevention has basically been coded language for weight loss and overzealous dietary restriction and exercise for a while now.
I’ll try to find the source – but I do remember quite clearly that it used to be that the canon in health practice saw homosexuality as a mental illness and leading to poorer health outcomes.(From my mom’s generation’s health classes.)
I remember my family arguing this was because of discrimination/stigma leading to poorer health outcomes. I haven’t heard this argument often these days, but I also live in Canada, where times are changing. The socio-economic status (of particularly gay male couples) is no longer as depressed by stigma. Homophobia still exists, and is still a real and present danger – but it’s not Charter entrenched anymore, and being gay no longer makes it likely you’ll be poor.
I think class really ends up being a big chunk of the issue. Class and health care access.
My experience in the LGBT community is that the health outcomes associated with marginalization tends more toward addiction and mental health although there could be other correlations I don’t know about.
As for income, that really depends on if you’re talking about male couples or female couples. Male couples have the income of two men and (often) no kids so they do pretty well, hence the massive efforts of many companies to target this niche market. Female couples have the income of two women and as such are less affluent than the men. I’d be interested to know if there are different health outcomes between lesbians and bi women versus gay and bi men. Then there’s the entire trans community which is a whole other level of marginalization.
Oh, right: and I’m beginning to suspect that class and fat is another chicken and egg thing. I have often heard that fat means poor due to lack of great choices, but my family has usually been both, and usually with superior choices. (My mom dealt with poverty, for example, by being vegetarian, renting a garden plot, and farming our food WHILE working a minimum wage job and going to university. In Ottawa. I grew up on whole grains and veggies, and lean proteins, primarily beans – because it was labour intensive but cheap. Plus we biked and walked everywhere. There’s no reason for us to be the size we are in the common parlance of why-people-are-fat; we just come this way.)
Anyway, who gets the high priced job? A fat person is seen by common prejudice to be perhaps nurturant and perhaps jolly (in the positive) but otherwise likely unable to cope with their emotions and lacking willpower (in the negative). Fat teacher? Okay. Fat CEO? Less likely. I mean, the fat are still having success – it’s not complete – but I think that prejudice these days has given fat an extra burden of association with traits that would tend to inhibit success.
Hmm. You know, I remember when I read the Obesity Myth I was shocked at how exaggerated the claims and concerns about obesity are, and I think it’s just the new sex – the new thing to moralize and freak out about. A “moral panic” as it’s been described.
But as to the question of why people are as fat as they are – which isn’t necessarily a big problem – I don’t remember whether I’ve seen the following theory refuted: that human beings evolved to survive famines and to do well under conditions where food was difficult to come by and required a lot of physical effort, and now that calorie dense food is – in the western world at least – is so easy to come by, we have a situation that enables us to comfortably maintain a higher body fat percentage then the “good old days” when people hunted and sometimes starved and lived on average a very short time compared to now. Am I wrong to think that?
I also think – speaking for myself – that weight takes on a much bigger importance under the guise of health. When I am told that I should lose weight to improve my cholesterol levels, (which run in my family even in family members who are not fat at all,) it’s a lot harder – emotionally – than when I’m told I should floss more or that I shouldn’t take so much ibuprofin even if I have a lot of headaches, or that it’s possible that the birth control pills I’ve taken all these years are the cause of my migraines. (Actually that last one depresses me sometimes, but I don’t think it does so as much as advice to lose weight.)
I think it’s all wrapped up in how highly we value physical appearance, and how closely we connect thinness with attractiveness. There is always that fantasy that if I were truly beautiful and men swooned at my feet, it would just be, AMAZING. And of course, if I were thin, then somehow I would be beautiful in every way and everyone would find me irresistible. I think many women share this wish, and perhaps many men as well. And I think THAT’s what spirals and “health concern” about weight (valid or not) out of control.
Sorry if I’m digressing…
cggirl –
I don’t think you’re digressing at all, but even if you were, I love digressions.
I think it’s all wrapped up in how highly we value physical appearance, and how closely we connect thinness with attractiveness. There is always that fantasy that if I were truly beautiful and men swooned at my feet, it would just be, AMAZING. And of course, if I were thin, then somehow I would be beautiful in every way and everyone would find me irresistible. I think many women share this wish, and perhaps many men as well. And I think THAT’s what spirals and “health concern” about weight (valid or not) out of control.
This is exactly what I suspect as well. And, in fact, I have been there. I once lost weight (though I was still considered overweight by the BMI) and even though I was obviously more traditionally attractive, and I did get more attention, I felt worse about myself. I hated my body. I felt more insecure than I ever had.
Which led me to think that the whole thing I was chasing was an illusion, like a mirage — my goal post kept moving farther and farther away. And the privilege that I thought would be the answer to all my problems once I’d gained it (as Kate Harding describes in The Fantasy of Being Thin) did jack-shit for my actual happiness and well-being. It really was a fantasy, which is to say, false.
Being thinner didn’t make me any happier. It actually made me feel worse, because I was conscious of having given in to societal pressures to meet an arbitrary beauty standard. And I was in bad faith — I’d lied to myself, and told myself I’d been doing it for the sake of my health. But it was really about gaining privilege, and feeling morally superior.
cggirl, your point connects with an issue I’ve often pondered. As you note, we’re now in the situation where, perhaps for the first time, large numbers of people in the Western world can actually obtain enough food, containing sufficient nutrients, on a regular basis. Certainly we lived precariously during prehistory, but for most of history everyone but the very rich has lived on the verge of malnutrition, and that situation only changed relatively recently. It’s entirely possible that we don’t know how much a healthy, adequately nourished human body ‘should’ weigh. It may well be more than we used to weigh back when we had the Depression and rationing and rickets and other great stuff. (If indeed people were that much thinner then – I collect old photos, and they tend to suggest otherwise.)
On disease: we are of course also living longer than ever, in part thanks to better nutrition. Cardiovascular disease and most cancers get more common the older you get. Of course, from figures out last week, it seems the obese live longer anyway (didn’t we already have umpteen studies that proved that?). Anyone thought of that one? Should we all oblige and prevent these diseases by dying early of something else? Also, Tiana has a great point – the health risks of dieting itself rarely get a mention.
Sort of related, here’s something I found this week on the NCI website that gave me pause:
“If the associations between obesity and the cancers mentioned above are causal, which has yet to be established, the current increase in the prevalence of obesity in the United States and elsewhere poses a severe challenge to cancer prevention efforts. Furthermore, weight loss has yet to be shown to reduce risk of obesity-associated malignancies.”
That’s the healthcare provider version. The patient version just gives a list of cancers ‘linked’ to obesity, although to its credit, it’s honest about the fact that weight loss isn’t known to reduce risk. This isn’t quite the message you hear in the media (and in places where they should know better – Cancer Research UK’s website, aimed at the general public, actually uses the exact words ‘obesity causes cancer’, and claims that weight loss must reduce risk even though nobody’s yet completed any studies on it). Not only dishonest, but encourages the blame game, and draws attention away from more easily correctable risk factors like health inequities – I seem to recall at least one study has shown that fat women are less likely to get mammograms because of how they’re treated by healthcare providers. I’m training in cancer registry, and while this misinformation annoys me, I’m sure it’s really no help to anyone who’s been diagnosed.
Emerald, you made an excellent point when you said
for most of history everyone but the very rich has lived on the verge of malnutrition, and that situation only changed relatively recently. It’s entirely possible that we don’t know how much a healthy, adequately nourished human body ’should’ weigh.
I totally agree. This is the first time food systems (and there are of course political criticisms to be made of those systems, their ethical implications, and their impact on the environment) have been large and stable enough to provide good quality food to the majority of people living in rich countries. Along with better nutrition comes not only possibly higher weights, but a taller population. But, as Big Liberty pointed out in her post on the tall epidemic, the increase in height never gets the same alarmist media treatment that changes in weight have.
And, of course, life expectancy has continued to increase through this “epidemic” as well. So, you know…
Also, as far as I heard, the NHANES data (article here) analysis showed no increase in obesity among the US population since 2004 or so.
then maybe it would be useful to put down the keys to the blame-mobile for just a moment
I snorgged my morning smoothie thru my nose reading that. I may use this when I talk to people:
Me: Honk Honk!! Here that? Yeah that’s the blame mobile and it just parked in your driveway.
LOL You Rock!
Stress is extremely complicated and likely to be implicated in whole bunches of things. Poverty is also associated with many many things that can be linked to fat and ill health such as:
1. Less sleep, either from worry or from working harder just to live (buses and lines are time consuming and frustrating exercises that poor people can’t opt out of). Lack of sleep causes both stress and is implicated in fat and other health problems.
2. Much poverty is concentrated in cities, where air pollution and noise pollution are endemic (both cause more disease than we currently are aware of, I believe), where outside play and sunshine are in short supply, where you have to buy fresh vegetables and fruits because it’s difficult to grow your own.
3. Less access to adequate health care, if you wait for an emergency to take care of a health problem, your health will suffer. Basic, but tends to be forgotten.
Plus, hey as a population we haven’t gotten much fatter really, I hear about fifteen pounds; I wonder how much of this increase in fatness is simply because we are older as a population than we used to be. Older people tend to be fatter than younger people. I easily weigh forty more pounds than I did in my twenties. And hey, older people get sicker too.
You say:
“Older people tend to be fatter than younger people. I easily weigh forty more pounds than I did in my twenties”
as if its a natural fact of life. It’s not. That your body is not effectively metabolising food is a function of how you have treated it over the years. Disease is cumulative. Insulin resistance and Metabolic Syndrome are largely responsible for most of the weight problems we see today – and they are the result of years of poor eating habits. Curb your sugar, alcohol, white flour, white rice and potatoes. Dismiss fake foods from boxes and cans. Take some responsibility, and there’s not excuse for emotional eating. Not anymore. We’ve all had it rough.
“Insulin resistance and Metabolic Syndrome are largely responsible for most of the weight problems we see today”
Oh! I’m glad you got that all sorted out, then.
“Curb your sugar, alcohol, white flour, white rice and potatoes.”
Surely, potatoes (the main source of vitamin C for much of North America) are of TEH DEVIL!!!
“Dismiss fake foods from boxes and cans.”
Yeah, man. All that oatmeal and those canned tomatoes are killing babies.
“Take some responsibility, and there’s not excuse for emotional eating. Not anymore. We’ve all had it rough.”
Clearly, NO ONE HAS AN EXCUSE FOR EATING IN WAYS OF WHICH YOU DISAPPROVE. Such compassion. I am…overwhelmed.
But seriously, Kasha, no one here is buying what you’re selling. Go live it up on your own website.
Ah, and there is some evidence that stress may speed aging:
http://www.sciencedaily.com/releases/2009/03/090316151033.htm
There seems to be a link to obesity as well, but I’d argue that fat people are always more stressed due to discrimination too. If stressed people are effectively older than their year age, that would explain a lot of health problems too.
Piffle –
I’d argue that fat people are always more stressed due to discrimination too. If stressed people are effectively older than their year age, that would explain a lot of health problems too.
Yes. That’s pretty much the argument made by Peter Muennig in the last journal article I linked. I think it’s a provocative, and quite possible, hypothesis. There have been other studies on this phenomenon among other marginalized groups. I believe the term used is “oppression syndrome.” I need to read more about it.
Ah Piffle I quite agree with the age thing – how people tend to weigh more as they age, and so living longer on average (a good thing) affects the average weight of the population (and causes people to freak out as if this is a bad thing) – it’s so true.
Excellent post! This elegantly sums up so much. Thank you.
@ Kelly: “To me this indicates that health has not much to do with what size you are, and more to do with the choice that comes with privilege.”
THIS.
I’d also like to trot out the oldie but goodie: “Correlation does not imply causation.”
You guys are awesome, and I want to respond to everything RIGHT NOW. Except…it’s Saturday night, and I’m drinking beer.
But I will be back Monday to respond to all you brilliant whipper-snappers.
Is drinking beer something you do often? It raises your insulin and halts fat burning, in addition to containing lots of calories from simple sugars that will be stored as fat while you sleep.
I’m sure drinking beer is something I do far more often than you’d approve of, Kasha (which is to say, since I do it at all.) But thanks for the, uh, nutrition lesson all the same.
Hey, Piffle- we may have polluted air, but people, particularly poor people, in cities are often quite physically active with all the walking, biking, and dealing with public transport (which usually involves walking and/or stairs) and, believe it or not, grow some of their own food as well. Also, in many (though not all) cities, there’s very high quality, cheap food available to poor people. I feel a blog post coming on…
It seems that by the time health, nutrition, exercise studies get filtered to the mainstream media, it seems that “obesity” and “bad diet and exercise” become used interchangeably, and it’s not what the science/study is saying, it’s just the prejudice/filter that many seem to have. This pisses me off, because it really clouds the health issue. I know overweight people who exerise plenty, I know slim people who wouldn’t know a vegetable if it smacked them in the face as they drive a block to the corner store for a microwave burrito. If you asked me who would be more likely to end up with diabetes, I would say that latter, and I believe many wouldn’t agree with me.
There’s just too much vitriol over weight for it to be about health, I think it’s mostly about looks and behavior control, and has become a moral issue, which helps nobody (except the diet industry).
Julie:
I know slim people who wouldn’t know a vegetable if it smacked them in the face as they drive a block to the corner store for a microwave burrito.
I’m sorry to out him in this disgraceful way, but my husband is one of those slim people. Recently, I called him a “nutrition disaster” to his face, and he’s never forgiven me for it.
Yesterday, when we were buying groceries, I rounded the corner to the frozen aisle to find him holding a STACK of frozen dinners and a giant bottle of Pepsi. As he tossed them in the cart he said “NUTRITION DISASTER, WHAT DO YOU MEAN?”
Then, as we were checking out, he was paying as I bagged stuff up. He started telling the cashier, “Oh, all that boxed meat and soda is for my wife. She doesn’t eat very healthy, you know. All these vegetables and stuff are for me.” The cashier and I were laughing hysterically.
NB: I don’t actually think there’s anything wrong with eating frozen dinners and drinking pop. I just like to make fun of him.
The experience cggirl describes (“There is always that fantasy that if I were truly beautiful and men swooned at my feet, it would just be, AMAZING.”) was basically me in my 20’s.
I’m also reasonably sure that I was “supposed” to have been overweight (obese, probably), but yo-yo-dieting resulted in my weight being higher than it probably “should” be. (Note that it took me a lot time to see my behavior as yo-yo dieting. I always viewed it as lifestyle changes I didn’t have the willpower to maintain. I was able to maintain this fiction because I only used a commercial diet company once, and then briefly.)
If you asked me who would be more likely to end up with diabetes, I would say that latter, and I believe many wouldn’t agree with me.
Except even that is wrong. It might apply to heart disease, but with diabetes, you really need to be genetically predisposed to it. Perhaps if you eat a lot of sugar and don’t exercise, you’ll get it a few years earlier than you normally would have.
Other than that, you’re absolutely right though.
wonderful.
I agree in every single thought.
it`s driving me crazy!
PS: germany is reading you
Hi Polly! Welcome, and danke.
Yeah but what if your husband, who never gains weight, finds himself at age 40-50, blowing up faster than an airbag during a head-on collision? That sort of ‘collision’ with middle age can do that to you, and you never see it coming.
Congrats for your honorable mention in the NYT.
Ellis
Hahaha, thanks Dad. Very nice imagery there.