(Content warning: I use the word ‘fat’ in a reclaimed way as a neutral body descriptor)
Most reasonable human beings understand that being mean to larger-bodied people is unacceptable. My nutrition colleagues can agree with me that discriminating against people on the basis of their size is harmful and we can do more to both expose and end weight stigma. However, discussions about body size are inevitably followed by the ‘But what about health?’ question.
Concern over fat bodies and health veils the deeply held assumption that body fat is pathological; that body fat has direct causal links to and a linear relationship with disease. This manifests not only as distain for people of size, sanctioned in the name of health, but also an internalised fear of weight gain – as if a subtle shift of 0.1kg from one BMI threshold to the next automatically brings immediate risks for life threatening diseases. These fear-based responses to health are, ironically, powerful antagonists to wellbeing. So, I sat down to write a blog post that clearly and carefully explains what we know (and what we don’t know) about body fat and health.
I planned to emphasize how physical activity reduces blood pressure, improves insulin resistance and improves blood lipids and how these improvements can take place independently of weight change. Similarly, gentle dietary changes can improve blood pressure (via salt reduction) and blood lipids (via saturated fat reduction) again, completely independently of body weight. I wanted to share how the universal acceptance of ‘fat is bad’ becomes the sole justification and rationale for weight control studies without the usual scientific and ethical rigour. I intended to highlight studies that do not control for a history of weight loss and regain (linked to heart conditions, stroke and poor bone health) and small studies with no control groups. Weight management research consistently attributes health improvements to weight loss even when studies are limited by extensive confounding. I was prepared for a discussion about how association is not causation; that thin bodies experience just the same health conditions as fat bodies and how BMI cut offs are arbitrary. I was ready to point out that there is no health condition (other than physiological and psychological distress caused by weight stigma) that is solely experienced by fat people.
Then I realised I had completely missed the point. I had fallen into the trap set by ‘concern trolling’, that is, the expression of a concern about an issue (in this case, health) in an attempt to undermine or derail the original discussion (disrespect shown to people with higher-than-average body fat).
So, here’s the thing about the ‘But what about health?’ narrative.
Even if body fat did directly cause disease, all bodies still deserve the same respect, care and equal treatment.
We know that fat shaming stops higher weight people from going to the doctor and when they do, they do not get the same treatment that thin people get. For example, a thin person with osteoarthritis may get access to physiotherapy, heat therapy or corticosteroids, whereas a fat person is told to lose weight (which we know is ineffective in the long term and carries adverse side effects), meanwhile their osteoarthritis goes untreated. This stigma and weight bias in healthcare goes a long way in explaining poorer health outcomes for fat people. If one good thing could possibly come from the covid-19 crisis, it is the compassion and understanding that social inequalities drive poor health. The ‘personal responsibility’ rhetoric is failing us just as much as the attempts to get us to ‘eat less and move more.’ We know we live in a society that wants to shrink us and at the same time, to consume (remember ‘eat out to help out’). Not to mention the money and resources spend on campaigns to make people smaller rather than actually improving access to healthcare, housing, creating food security and reducing income inequalities.
We know bodies are different and we know that health is multifaceted. People of all shapes and sizes are living with the whole spectrum of health conditions. Not everyone can be healthy. Health is not a badge of honour. It is how we collectively care for people and view and respond to ‘health’ that is the true measure of human kindness.