Everything You Know About Obesity Is Wrong - It's Time For A
New Paradigm
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| I have never written a story where
so many of my sources cried during interviews |
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| By Michael Hobbes |
Huffington Post |
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 From
the 16th century to the 19th, scurvy killed around 2 million
sailors, more than warfare, shipwrecks and syphilis combined. It
was an ugly, smelly death, too, beginning with rattling teeth
and ending with a body so rotted out from the inside that its
victims could literally be startled to death by a loud noise.
Just as horrifying as the disease itself, though, is that for
most of those 300 years, medical experts knew how to prevent it
and simply failed to.
In the 1600s, some sea captains distributed lemons, limes and
oranges to sailors, driven by the belief that a daily dose of
citrus fruit would stave off scurvy’s progress. The British
Navy, wary of the cost of expanding the treatment, turned to
malt wort, a mashed and cooked byproduct of barley which had the
advantage of being cheaper but the disadvantage of doing nothing
whatsoever to cure scurvy. In 1747, a British doctor named James
Lind conducted an experiment where he gave one group of sailors
citrus slices and the others vinegar or seawater or cider. The
results couldn’t have been clearer. The crewmen who ate fruit
improved so quickly that they were able to help care for the
others as they languished. Lind published his findings, but died
before anyone got around to implementing them nearly 50 years
later.
This kind of myopia repeats throughout history. Seat belts were
invented long before the automobile but weren’t mandatory in
cars until the 1960s. The first confirmed death from asbestos
exposure was recorded in 1906, but the U.S. didn’t start banning
the chemical until 1973. Every discovery in public health, no
matter how significant, must compete with the traditions,
assumptions and financial incentives of the society implementing
it.
Which brings us to one of the largest gaps between science and
practice in our own time. Years from now, we will look back in
horror at the counterproductive ways we addressed the obesity
epidemic and the barbaric ways we treated fat people—long after
we knew there was a better path.
I have never written a story where so many of my sources cried
during interviews, where they shook with anger describing their
interactions with doctors and strangers and their own families.
About 40 years ago, Americans started getting much larger.
According to the Centers for Disease Control and Prevention,
nearly 80 percent of adults and about one-third of children now
meet the clinical definition of overweight or obese. More
Americans live with “extreme obesity“ than with breast cancer,
Parkinson’s, Alzheimer’s and HIV put together.
And the medical community’s primary response to this shift has
been to blame fat people for being fat. Obesity, we are told, is
a personal failing that strains our health care system, shrinks
our GDP and saps our military strength. It is also an excuse to
bully fat people in one sentence and then inform them in the
next that you are doing it for their own good. That’s why the
fear of becoming fat, or staying that way, drives Americans to
spend more on dieting every year than we spend on video games or
movies. Forty-five percent of adults say they’re preoccupied
with their weight some or all of the time—an 11-point rise since
1990. Nearly half of 3- to 6- year old girls say they worry
about being fat.
The emotional costs are incalculable. I have never written a
story where so many of my sources cried during interviews, where
they double- and triple-checked that I would not reveal their
names, where they shook with anger describing their interactions
with doctors and strangers and their own families. One
remembered kids singing “Baby Beluga” as she boarded the school
bus, another said she has tried diets so extreme she has passed
out and yet another described the elaborate measures he takes to
keep his spouse from seeing him naked in the light. A medical
technician I’ll call Sam (he asked me to change his name so his
wife wouldn’t find out he spoke to me) said that one glimpse of
himself in a mirror can destroy his mood for days. “I have this
sense I’m fat and I shouldn’t be,” he says. “It feels like the
worst kind of weakness.”
My interest in this issue is slightly more than journalistic.
Growing up, my mother’s weight was the uncredited co-star of
every family drama, the obvious, unspoken reason why she never
got out of the car when she picked me up from school, why she
disappeared from the family photo album for years at a time, why
she spent hours making meatloaf then sat beside us eating a bowl
of carrots. Last year, for the first time, we talked about her
weight in detail. When I asked if she was ever bullied, she
recalled some guy calling her a “fat slob” as she biked past him
years ago. “But that was rare,” she says. “The bigger way my
weight affected my life was that I waited to do things because I
thought fat people couldn’t do them.” She got her master’s
degree at 38, her Ph.D. at 55. “I avoided so many activities
where I thought my weight would discredit me.”
Chances of a woman classified as obese achieving a “normal”
weight:.008%Source: American Journal of Public Health, 2015
But my mother’s story, like Sam’s, like everyone’s, didn’t have
to turn out like this. For 60 years, doctors and researchers
have known two things that could have improved, or even saved,
millions of lives. The first is that diets do not work. Not just
paleo or Atkins or Weight Watchers or Goop, but all diets. Since
1959, research has shown that 95 to 98 percent of attempts to
lose weight fail and that two-thirds of dieters gain back more
than they lost. The reasons are biological and irreversible. As
early as 1969, research showed that losing just 3 percent of
your body weight resulted in a 17 percent slowdown in your
metabolism—a body-wide starvation response that blasts you with
hunger hormones and drops your internal temperature until you
rise back to your highest weight. Keeping weight off means
fighting your body’s energy-regulation system and battling
hunger all day, every day, for the rest of your life.
The second big lesson the medical establishment has learned and
rejected over and over again is that weight and health are not
perfect synonyms. Yes, nearly every population-level study finds
that fat people have worse cardiovascular health than thin
people. But individuals are not averages: Studies have found
that anywhere from one-third to three-quarters of people
classified as obese are metabolically healthy. They show no
signs of elevated blood pressure, insulin resistance or high
cholesterol. Meanwhile, about a quarter of non-overweight people
are what epidemiologists call “the lean unhealthy.” A 2016 study
that followed participants for an average of 19 years found that
unfit skinny people were twice as likely to get diabetes as fit
fat people. Habits, no matter your size, are what really matter.
Dozens of indicators, from vegetable consumption to regular
exercise to grip strength, provide a better snapshot of
someone’s health than looking at her from across a room.
The terrible irony is that for 60 years, we’ve approached the
obesity epidemic like a fad dieter: If we just try the exact
same thing one more time, we'll get a different result. And so
it’s time for a paradigm shift. We’re not going to become a
skinnier country. But we still have a chance to become a
healthier one. |
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“As a kid, I thought that fat
people were just lonely and sad—almost like these pathetic lost
causes. So I want to show that we get to experience love, too.
I’m not some 'fat friend' or some dude's chubby chasing dream.
I'm genuinely happy. I just wish I'd known how possible that was
when I was a kiddo.”— CORISSA ENNEKING |
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This is Corissa Enneking at her lightest:
She wakes up, showers and smokes a cigarette to keep her
appetite down. She drives to her job at a furniture store, she
stands in four-inch heels all day, she eats a cup of yogurt
alone in her car on her lunch break. After work, lightheaded,
her feet throbbing, she counts out three Ritz crackers, eats
them at her kitchen counter and writes down the calories in her
food journal.
Or not. Some days she comes home and goes straight to bed,
exhausted and dizzy from hunger, shivering in the Kansas heat.
She rouses herself around dinnertime and drinks some orange
juice or eats half a granola bar. Occasionally she’ll just sleep
through the night, waking up the next day to start all over
again.
The last time she lived like this, a few years ago, her mother
marched her to the hospital. “My daughter is sick,” she told the
doctor. “She's not eating.” He looked Enneking up and down.
Despite six months of starvation, she was still wearing plus
sizes, still couldn’t shop at J. Crew, still got unsolicited
diet advice from colleagues and customers.
Enneking told the doctor that she used to be larger, that she’d
lost some weight the same way she had lost it three or four
times before—seeing how far she could get through the day
without eating, trading solids for liquids, food for sleep. She
was hungry all the time, but she was learning to like it. When
she did eat, she got panic attacks. Her boss was starting to
notice her erratic behavior.
“Well, whatever you're doing now,” the doctor said, “it's
working.” He urged her to keep it up and assured her that once
she got small enough, her body would start to process food
differently. She could add a few hundred calories to her diet.
Her period would come back. She would stay small, but without as
much effort.
“If you looked at anything other than my weight,” Enneking says
now, “I had an eating disorder. And my doctor was congratulating
me.”
Ask almost any fat person about her interactions with the health
care system and you will hear a story, sometimes three, the same
as Enneking’s: rolled eyes, skeptical questions, treatments
denied or delayed or revoked. Doctors are supposed to be trusted
authorities, a patient’s primary gateway to healing. But for fat
people, they are a source of unique and persistent trauma. No
matter what you go in for or how much you’re hurting, the first
thing you will be told is that it would all get better if you
could just put down the Cheetos.
Emily went to a gynecological surgeon to have an ovarian cyst
removed. The physician pointed out her body fat on the MRI, then
said, “Look at that skinny woman in there trying to get out.”
This phenomenon is not merely anecdotal. Doctors have shorter
appointments with fat patients and show less emotional rapport
in the minutes they do have. Negative words—“noncompliant,”
“overindulgent,” “weak willed”—pop up in their medical histories
with higher frequency. In one study, researchers presented
doctors with case histories of patients suffering from
migraines. With everything else being equal, the doctors
reported that the patients who were also classified as fat had a
worse attitude and were less likely to follow their advice. And
that’s when they see fat patients at all: In 2011, the
Sun-Sentinel polled OB-GYNs in South Florida and discovered that
14 percent had barred all new patients weighing more than 200
pounds.
Some of these doctors are simply applying the same presumptions
as the society around them. An anesthesiologist on the West
Coast tells me that as soon as a larger patient goes under, the
surgeons start trading “high school insults” about her body over
the operating table. Janice O’Keefe, a former nurse in Boston,
tells me a doctor once looked at her, paused, then asked, “How
could you do this to yourself?” Emily, a counselor in Eastern
Washington, went to a gynecological surgeon to have an ovarian
cyst removed. The physician pointed out her body fat on the MRI,
then said, “Look at that skinny woman in there trying to get
out.”
“I was worried I had cancer,” Emily says, “and she was turning
it into a teachable moment about my weight.”
Other physicians sincerely believe that shaming fat people is
the best way to motivate them to lose weight. “It’s the last
area of medicine where we prescribe tough love,” says Mayo
Clinic researcher Sean Phelan.
In a 2013 journal article, bioethicist Daniel Callahan argued
for more stigma against fat people. “People don’t realize that
they are obese or if they do realize it, it’s not enough to stir
them to do anything about it,” he tells me. Shame helped him
kick his cigarette habit, he argues, so it should work for
obesity too.
This belief is cartoonishly out of step with a generation of
research into obesity and human behavior. As one of the (many)
stigma researchers who responded to Callahan’s article pointed
out, shaming smokers and drug users with D.A.R.E.-style “just
say no” messages may have actually increased substance abuse by
making addicts less likely to bring up their habit with their
doctors and family members.
Plus, rather obviously, smoking is a behavior; being fat is not.
Jody Dushay, an endocrinologist and obesity specialist at Beth
Israel Deaconess Medical Center in Boston, says most of her
patients have tried dozens of diets and have lost and regained
hundreds of pounds before they come to her. Telling them to try
again, but in harsher terms, only sets them up to fail and then
blame themselves.
89%of obese adults have been bullied by their romantic
partnersSource: University of Connecticut, 2017
Not all physicians set out to denigrate their fat patients, of
course; some of them do damage because of subtler, more
unconscious biases. Most doctors, for example, are fit—“If you
go to an obesity conference, good luck trying to get a treadmill
at 5 a.m.,” Dushay says—and have spent more than a decade of
their lives in the high-stakes, high-stress bubble of medical
schools. According to several studies, thin doctors are more
confident in their recommendations, expect their patients to
lose more weight and are more likely to think dieting is easy.
Sarah (not her real name), a tech CEO in New England, once told
her doctor that she was having trouble eating less throughout
the day. “Look at me,” her doctor said. “I had one egg for
breakfast and I feel fine.”
Then there are the glaring cultural differences. Kenneth
Resnicow, a consultant who trains physicians to build rapport
with their patients, says white, wealthy, skinny doctors will
often try to bond with their low-income patients by telling
them, “I know what it’s like not to have time to cook.” Their
patients, who might be single mothers with three kids and two
jobs, immediately think “No, you don’t,” and the relationship is
irretrievably soured.
When Joy Cox, an academic in New Jersey, was 16, she went to the
hospital with stomach pains. The doctor didn’t diagnose her
dangerously inflamed bile duct, but he did, out of nowhere,
suggest that she’d get better if she stopped eating so much
fried chicken. “He managed to denigrate my fatness and my
blackness in the same sentence,” she says. |
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“There is so much agency taken
from marginalized groups to mute their voices and mask their
existence. Being depicted as a female CEO—one who is also black
and fat—means so much to me. It is a representation of the
reclamation of power in the boardroom, classroom and living room
of my body. I own all of this.”— JOY COX |
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Many of the financial and administrative
structures doctors work within help reinforce this bad behavior.
The problem starts in medical school, where, according to a 2015
survey, students receive an average of just 19 hours of
nutrition education over four years of instruction—five hours
fewer than they got in 2006. Then the trouble compounds once
doctors get into daily practice. Primary care physicians only
get 15 minutes for each appointment, barely enough time to ask
patients what they ate today, much less during all the years
leading up to it. And a more empathic approach to treatment
simply doesn’t pay: While procedures like blood tests and CT
scans command reimbursement rates from hundreds to thousands of
dollars, doctors receive as little as $24 to provide a session
of diet and nutrition counseling.
Lesley Williams, a family medicine doctor in Phoenix, tells me
she gets an alert from her electronic health records software
every time she’s about to see a patient who is above the
“overweight” threshold. The reason for this is that physicians
are often required, in writing, to prove to hospital
administrators and insurance providers that they have brought up
their patient’s weight and formulated a plan to bring it
down—regardless of whether that patient came in with arthritis
or a broken arm or a bad sunburn. Failing to do that could
result in poor performance reviews, low ratings from insurance
companies or being denied reimbursement if they refer patients
to specialized care.
Another issue, says Kimberly Gudzune, an obesity specialist at
Johns Hopkins, is that many doctors, no matter their specialty,
think weight falls under their authority. Gudzune often spends
months working with patients to set realistic goals—playing with
their grandkids longer, going off a cholesterol medication—only
to have other doctors threaten it all. One of her patients was
making significant progress until she went to a cardiologist who
told her to lose 100 pounds. “All of a sudden she goes back to
feeling like a failure and we have to start over,” Gudzune says.
“Or maybe she just never comes back at all.”
60%of the calories Americans consume come from “ultra-processed
foods”Source: British Medical Journal, 2016
And so, working within a system that neither trains nor
encourages them to meaningfully engage with their higher-weight
patients, doctors fall back on recommending fad diets and
delivering bland motivational platitudes. Ron Kirk, an
electrician in Boston, says that for years, his doctor's first
resort was to put him on some diet he couldn't maintain for more
than a few weeks. “They told me lettuce was a ‘free’ food,” he
says—and he’d find himself carving up a head of romaine for
dinner.
In a study that recorded 461 interactions with doctors, only 13
percent of patients got any specific plan for diet or exercise
and only 5 percent got help arranging a follow-up visit. “It can
be stressful when [patients] start asking a lot of specific
questions” about diet and weight loss, one doctor told
researchers in 2012. “I don’t feel like I have the time to sit
there and give them private counseling on basics. I say, ‘Here’s
some websites, look at this.’” A 2016 survey found that nearly
twice as many higher-weight Americans have tried
meal-replacement diets—the kind most likely to fail—than have
ever received counseling from a dietician.
“It borders on medical malpractice,” says Andrew (not his real
name), a consultant and musician who has been large his whole
life. A few years ago, on a routine visit, Andrew’s doctor
weighed him, announced that he was “dangerously overweight” and
told him to diet and exercise, offering no further specifics.
Should he go on a low-fat diet? Low-carb? Become a vegetarian?
Should he do Crossfit? Yoga? Should he buy a fucking
ThighMaster?
“She didn't even ask me what I was already doing for exercise,”
he says. “At the time, I was training for serious winter
mountaineering trips, hiking every weekend and going to the gym
four times a week. Instead of a conversation, I got a sound
bite. It felt like shaming me was the entire purpose.”
All of this makes higher-weight patients more likely to avoid
doctors. Three separate studies have found that fat women are
more likely to die from breast and cervical cancers than non-fat
women, a result partially attributed to their reluctance to see
doctors and get screenings. Erin Harrop, a researcher at the
University of Washington, studies higher-weight women with
anorexia, who, contrary to the size-zero stereotype of most
media depictions, are twice as likely to report vomiting, using
laxatives and abusing diet pills. Thin women, Harrop discovered,
take around three years to get into treatment, while her
participants spent an average of 13 and a half years waiting for
their disorders to be addressed.
“A lot of my job is helping people heal from the trauma of
interacting with the medical system,” says Ginette Lenham, a
counselor who specializes in obesity. The rest of it, she says,
is helping them heal from the trauma of interacting with
everyone else. |
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“My weight makes me anxious. I'm
constantly sucking my stomach in when I stand, and if I'm
sitting, I always grab a pillow or couch cushion to hold in
front of it. I'm most comfortable in my bathrobe, alone. At the
same time, my brain starves for attention. I want to be onstage.
I want to be the one holding a microphone. So, I decided to
split the difference with this photograph: to perform and to
obscure. The worst part is that intellectually I know that I
have worth beyond pounds and waist inches and stereotypes. But I
still feel like I have to hide.”— SAM (NOT HIS REAL NAME) |
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If Sonya ever forgets that she is fat, the
world will remind her. She has stopped taking the bus, she tells
me, because she can sense the aggravation of the passengers
squeezing past her. Sarah, the tech CEO, tenses up when anyone
brings bagels to a work meeting. If she reaches for one, are her
employees thinking, “There goes the fat boss”? If she doesn’t,
are they silently congratulating her for showing some restraint?
Emily says it’s the do-gooders who get to her, the women who
stop her on the street and tell her how brave she is for wearing
a sleeveless dress on a 95-degree day. Sam, the medical
technician, avoids the subject of weight altogether. “Men aren’t
supposed to think about this stuff—and I think about it
constantly,” he admits. “So I never let myself talk about it.
Which is weird because it’s the most visible thing about me.”
Again and again I hear stories of how the pressure to be a “good
fatty” in public builds up and explodes. Jessica has four kids.
Every week is a birthday party or family reunion or swimming
pool social, another opportunity to stand around platters of
spare ribs and dinner rolls with her fellow moms.
“Your conscious mind is busy the whole day with how many
calories is in everything, what you can eat and who’s watching,”
she says. After a few intrusive comments over the years—should
you be eating that?—she has learned to be careful, to perform
the role of the impeccable fat person. She nibbles on cherry
tomatoes, drinks tap water, stays on her feet, ignores the
dessert end of the buffet.
Then, as the gathering winds down, Jessica and the other parents
divvy up the leftovers. She wraps up burgers or pasta salad or
birthday cake, drives her children home and waits for the moment
when they are finally in bed. Then, when she’s alone, she eats
all the leftovers by herself, in the dark.
“It’s always hidden,” she says. “I buy a package of ice cream,
then eat it all. Then I have to go to the store to buy it again.
For a week my family thinks there’s a thing of ice cream in the
fridge—but it’s actually five different ones.”
Ratio of soda and candy ads seen by black children compared to
white children:2:1Source: UConn Rudd Center for Food Policy and
Obesity, 2015
This is how fat-shaming works: It is visible and invisible,
public and private, hidden and everywhere at the same time.
Research consistently finds that larger Americans (especially
larger women) earn lower salaries and are less likely to be
hired and promoted. In a 2017 survey, 500 hiring managers were
given a photo of an overweight female applicant. Twenty-one
percent of them described her as unprofessional despite having
no other information about her. What’s worse, only a few cities
and one state (nice work, Michigan) officially prohibit
workplace discrimination on the basis of weight.
Paradoxically, as the number of larger Americans has risen, the
biases against them have become more severe. More than 40
percent of Americans classified as obese now say they experience
stigma on a daily basis, a rate far higher than any other
minority group. And this does terrible things to their bodies.
According to a 2015 study, fat people who feel discriminated
against have shorter life expectancies than fat people who
don't. “These findings suggest the possibility that the stigma
associated with being overweight,” the study concluded, “is more
harmful than actually being overweight.”
And, in a cruel twist, one effect of weight bias is that it
actually makes you eat more. The stress hormone cortisol—the one
evolution designed to kick in when you’re being chased by a
tiger or, it turns out, rejected for your looks—increases
appetite, reduces the will to exercise and even improves the
taste of food. Sam, echoing so many of the other people I spoke
with, says that he drove straight to Jack in the Box last year
after someone yelled, “Eat less!” at him across a parking lot. |
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“I don’t want to be portrayed;
this is not about me. It’s about that guy you always see on the
far treadmill at the gym. Or the lady who brings the most
beautiful salads to work every day for lunch. It’s about the
little girl who got bullied because of her size, and the little
boy who was told he wasn’t man enough. It’s not about me, but
had it been about me when I was that chubby little girl, maybe I
wouldn’t be standing here, head against the door, wondering if
I’m enough.”— ERIKA |
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There’s a grim caveman logic to our
nastiness toward fat people. “We’re attuned to bodies that look
different,” says Janet Tomiyama, a stigma researcher at UCLA.
“In our evolutionary past, that might have meant disease risk
and been seen as a threat to your tribe.” These biological
breadcrumbs help explain why stigma begins so early. Kids as
young as 3 describe their larger classmates with words like
“mean,” “stupid” and “lazy.”
And yet, despite weight being the number one reason children are
bullied at school, America’s institutions of public health
continue to pursue policies perfectly designed to inflame the
cruelty. TV and billboard campaigns still use slogans like “Too
much screen time, too much kid” and “Being fat takes the fun out
of being a kid.” Cat Pausé, a researcher at Massey University in
New Zealand, spent months looking for a single public health
campaign, worldwide, that attempted to reduce stigma against fat
people and came up empty. In an incendiary case of good
intentions gone bad, about a dozen states now send children home
with “BMI report cards,” an intervention unlikely to have any
effect on their weight but almost certain to increase bullying
from the people closest to them.
This is not an abstract concern: Surveys of higher-weight adults
find that their worst experiences of discrimination come from
their own families. Erika, a health educator in Washington, can
still recite the word her father used to describe her: “husky.”
Her grandfather preferred “stocky.” Her mother never said
anything about Erika’s body, but she didn't have to. She
obsessed over her own, calling herself “enormous” despite being
two sizes smaller than her daughter. By the time Erika was 11,
she was sneaking into the woods behind her house and vomiting
into the creek whenever social occasions made starving herself
impossible.
And the abuse from loved ones continues well into adulthood. A
2017 survey found that 89 percent of obese adults had been
bullied by their romantic partners. Emily, the counselor, says
she spent her teens and 20s “sleeping with guys I wasn’t
interested in because they wanted to sleep with me.” In her
head, a guy being into her was a rare and depletable resource
she couldn’t afford to waste: “I was desperate for men to give
me attention. Sex was a good way to do that.”
Eventually, she ended up with someone abusive. He told her
during sex that her body was beautiful and then, in the
daylight, that it was revolting. “Whenever I tried to leave him,
he would say, ‘Where are you gonna find someone who will put up
with your disgusting body?’” she remembers.
Emily finally managed to get away from him, but she is aware
that her love life will always be fraught. The guy she’s dating
now is thin—“think Tony Hawk,” she says—and she notices the
looks they get when they hold hands in public. “That never used
to happen when I dated fat dudes,” she says. “Thin men are not
allowed to be attracted to fat women.”
The effects of weight bias get worse when they’re layered on top
of other types of discrimination. A 2012 study found that
African-American women are more likely to become depressed after
internalizing weight stigma than white women. Hispanic and black
teenagers also have significantly higher rates of bulimia. And,
in a remarkable finding, rich people of color have higher rates
of cardiovascular disease than poor people of color—the opposite
of what happens with white people. One explanation is that
navigating increasingly white spaces, and increasingly higher
stakes, exerts stress on racial minorities that, over time,
makes them more susceptible to heart problems.
But perhaps the most unique aspect of weight stigma is how it
isolates its victims from one another. For most minority groups,
discrimination contributes to a sense of belongingness, a
community in opposition to a majority. Gay people like other gay
people; Mormons root for other Mormons. Surveys of higher-weight
people, however, reveal that they hold many of the same biases
as the people discriminating against them. In a 2005 study, the
words obese participants used to classify other obese people
included gluttonous, unclean and sluggish.
Andrea, a retired nurse in Boston, has been on commercial diets
since she was 10 years old. She knows how hard it is to slim
down, knows what women larger than her are going through, but
she still struggles not to pass judgment when she sees them in
public. “I think, ‘How did they let it happen?’” she says. “It’s
more like fear. Because if I let myself go, I’ll be that big
too.”
Her position is all-too understandable. As young as 9 or 10, I
knew that coming out of the closet is what gay people do, even
if it took me another decade to actually do it. Fat people,
though, never get a moment of declaring their identity, of
marking themselves as part of a distinct group. They still live
in a society that believes weight is temporary, that losing it
is urgent and achievable, that being comfortable in their bodies
is merely “glorifying obesity.” This limbo, this lie, is why
it’s so hard for fat people to discover one another or even
themselves. “No one believes our It Gets Better story,” says
Tigress Osborn, the director of community outreach for the
National Association to Advance Fat Acceptance. “You can’t claim
an identity if everyone around you is saying it doesn’t or
shouldn’t exist.”
Harrop, the eating disorders researcher, realized several years
ago that her university had clubs for trans students, immigrant
students, Republican students, but none for fat students. So she
started one—and it has been a resounding, unmitigated failure.
Only a handful of fat people have ever showed up; most of the
time, thin folks sit around brainstorming about how to be better
allies.
I ask Harrop why she thinks the group has been such a bust. It’s
simple, she says: “Fat people grow up in the same fat-hating
culture that non-fat people do.” |
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“I think some folks are
genuinely surprised that a man who looks like him is with a
woman like me. As a fat person, I'm very aware of when I'm being
stared at—and I have never been looked at this much before. So I
thought that taking the photo in public would be a good idea. It
feels subversive to show my fat body doing regular stuff the
world believes I don't or can't do.”— EMILY |
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“My son and I both like to play the hero. There wasn't necessarily any
intentional symbolism in the costumes we chose, but I am definitely a member
of the rebellion, and I see my role as an eating disorders researcher as
trying to fight for justice and a better world. Also, I like that I'm
sweaty, dirty and messy, not done up with makeup or with my hair down in
this picture. I like that I'm not hiding my stomach, thighs or arms. Not
because I'm comfortable being photographed like that, but because I want to
be—and I want others to feel free to be like that, too.”— ERIN HARROP |
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The problem is that in America, like everywhere else, our institutions of public health have become so obsessed with body weight that they have overlooked what is really killing us: our food supply. Diet is the leading cause of death in the United States, responsible for more than five times the fatalities of gun violence and car accidents combined. But it’s not how much we’re eating—Americans actually consume fewer calories now than we did in 2003. It’s what we’re eating.
For more than a decade now, researchers have found that the quality of our food affects disease risk independently of its effect on weight. Fructose, for example, appears to damage insulin sensitivity and liver function more than other sweeteners with the same number of calories. People who eat nuts four times a week have 12 percent lower diabetes incidence and a 13 percent lower mortality rate regardless of their weight. All of our biological systems for regulating energy, hunger and satiety get thrown off by eating foods that are high in sugar, low in fiber and injected with additives. And which now, shockingly, make up 60 percent of the calories we eat.
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.”
4%of all agricultural subsidies go to fruits and vegetablesSource: Environmental Working Group, 2014-16
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.
It’s the same with exercise. The cardiovascular risks of sedentary lifestyles, suburban sprawl and long commutes are well-documented. But rather than help mitigate these risks—and their disproportionate impact on the poor—our institutions have exacerbated them. Only 13 percent of American children walk or bike to school; once they arrive, less than a third of them will take part in a daily gym class. Among adults, the number of workers commuting more than 90 minutes each way grew by more than 15 percent from 2005 to 2016, a predictable outgrowth of America’s underinvestment in public transportation and over-investment in freeways, parking and strip malls. For 40 years, as politicians have told us to eat more vegetables and take the stairs instead of the elevator, they have presided over a country where daily exercise has become a luxury and eating well has become extortionate.