Dear Helen,
Hi! I’m writing to respond to your open letter, “on Fat Scholarship and Activism.”
A thousand words seems cruelly scant to me, but I’ll do my best.
For space reasons, I won’t dig into our “obesity vs fat” semantic disagreement. I suggest we each use our preferred word, neither making a fuss about the other’s choice. (Ditto for “fat acceptance” vs “fat activism.”)
Part 1: Your charges against the fat acceptance movement.
Your criticisms of fat acceptance are a mix of cherry-picked examples and uncharitable readings.
For instance, you say where fat activism “could oppose discrimination against obese people in the workplace, it goes on about ‘romantic discrimination.’” But the linked article contains only three paragraphs about “romantic discrimination,” a fraction of a much longer piece. (And do you really think cultural components of attraction aren’t worthy of being written about? I can’t agree.)
Your claim that fat acceptance “doesn’t do this kind of work” – meaning opposing things like workplace and medical discrimination – is staggeringly wrong. I could provide a hundred links of scholars and activists addressing those issues, but since time is limited, hopefully just ten will prove my point.
Your other indictments followed a similar pattern, but with only 1000 words, I must move on!
(This article by Angie Manfredi, aimed at teens, is a non-comprehensive but accurate overview of fat acceptance’s goals. And Yasmin Harker created this useful bibliography of academic works about fat rights and fat discrimination.)
Part 2: Why I’m Generally Anti-Diet
We both want to end stigma and discrimination against fat people. Where we disagree (if I’ve understood correctly) is that you think fat people should try to not be fat, and that fat people are by definition unhealthy.
Accepting for a moment, for argument’s sake, that fat is unhealthy, that doesn’t necessarily lead to the conclusion that most fat people should try not to be fat.
First, I’ll stress that no one is under any obligation to maximize health. Exercise and cooking can take time, space, money, and mental energy which not everyone has. And people can legitimately prioritize other things.
But some fat people do wish to prioritize their health. Shouldn’t those fat people be encouraged to lose weight?
Some should – people with specific, serious conditions that weight loss could help (even if they’d still be fat).
But for 99% of fat people, I’d say not. The evidence is clear that weight-loss plans don’t work for the large majority. Most never lose a significant amount of weight – certainly not enough for a fat person to stop being fat. And usually whatever weight is lost – or more – comes back within five years. This causes mental anguish, because failure to lose weight, or to maintain weight loss, easily turns into self-hatred. If the person tries multiple times (as is common), the physical effects of yo-yo dieting can be very harmful.
Wayne Miller, an exercise science specialist at George Washington University, wrote:
There isn’t even one peer-reviewed controlled clinical study of any intentional weight-loss diet that proves that people can be successful at long-term significant weight loss. No commercial program, clinical program, or research model has been able to demonstrate significant long-term weight loss for more than a small fraction of the participants. Given the potential dangers of weight cycling and repeated failure, it is unscientific and unethical to support the continued use of dieting as an intervention for obesity.
Am I saying fat people who want to be healthier should give up? Absolutely not. I’m saying becoming healthier doesn’t require futile attempts to lose weight.
Please look at this graph. (Source.) It shows likelihood of mortality as it relates to weight and four other characteristics: fruit and vegetable intake, tobacco use, exercise, and alcohol. These are sometimes called the “healthy habits.”
On the left side of the graph, fat people who practice no “healthy habits” – smoking, no veggies, immoderate drinking, no exercise – have a much higher mortality risk than so-called “normal” weight people with unhealthy habits (although the “normals” have elevated risk too).
On the right end of the graph, fat people who practice all four healthy habits have a mortality risk that’s just barely higher than their thinner counterparts. More importantly, we can see that fat people who practice all four healthy habits benefit enormously, compared to fat people who don’t. (“Normals” benefit enormously from these healthy habits, too.)
Most fat people can’t permanently lose enough weight to stop being fat. But most fat people can eat more veggies, can not smoke, can limit ourselves to one glass of hootch a day, can add moderate exercise to our lives. These things aren’t always easy, but they are all much more achievable, for most fat people, than stopping being fat.
Achievable advice is better than unachievable advice. There’s a positive way forward for most fat people who want to be healthier – one that’s more likely to work, and less likely to encourage self-hatred, than trying to stop being fat.
One final thought: stigma against being fat may be more harmful than fat itself.
These findings suggest the possibility that the stigma associated with being overweight is more harmful than actually being overweight… Growing evidence suggests that weight bias does not work; it leads to greater morbidity and, now, greater mortality.
(See also.)
Could we get rid of weight bias while still holding the belief that fat people must lose weight? I doubt it. Reducing stigma could do more for fat people’s health than reducing waistlines.
There’s so much more to say (harms of dieting; benefits of a Health At Every Size approach; how HAES can help with disordered eating; etc), but I’m out of space.
I hope this letter finds you happy, well, and socially distanced someplace very cozy.
Best wishes, Barry
Well done.
Hear, hear. Spread the word. And thanks.
1) You have far more patience than I do.
2) I feel so sorry for her.
1) It may seem that way… But you should see the sentences I write and then delete before anyone sees them!
Delete sentences before they’re seen? What witchcraft is this?
I hate to sound cruel, but ..
Data shows that around 60% of the dead owing to the coronavirus are obese. Even more for those younger than 55-60. And it seems to be an independent risk factor — independent from diabetes and hypertension.
Sure fat people can be healthy, but the fact is that a lot of obese people aren’t healthy. The virus is just brutally demonstrating this.
What I’ve been reading is that it is the second most important factor in death or serious hospitalization after age. As you mentioned, it’s not because of secondary effects like diabetes, it’s a risk factor in and of itself.
It may have something to do with inflammation in the body, enabling the “cytokine storm” that can cause death or really mess up the lungs.
Covid-19 Does Not Discriminate by Body Weight | WIRED
This article argues that the links between fat and Covid-19 are not nearly as well established as the media has been telling us.
But more importantly for this post (if not in the wider world), focusing on this ignores the primary argument of my response to Helen. As I said in my response to Helen, even granting for argument’s sake that fat is unhealthy, it doesn’t necessarily follow that fat people should be trying to stop being fat.
You’re talking about a population that is poorer and less white than their thin counterparts, first off. You’re also talking about a population that’s subject to a lot of stigma, including in healthcare. This is a double whammy for a person’s overall health, since experiencing stigma is unhealthy (I think “minority stress” is the term for that) and being denied healthcare until you lose weight also results in worse health.
A study could control for race and socioeconomic class. Controlling for known risk factors associated with weight like diabetes and hypertension probably helps with this some.
But ways of controlling for stigma are a lot more limited. There is no population of fat people in America who aren’t subject to weight discrimination who you could compare against. Other countries may have higher or lower levels of weight bias, but they also have different healthcare systems, governments, and reactions to the pandemic.
And when you’re talking about fatal cases, there’s no way to compare based on individual experiences. You can’t, for example, ask dead people how frequently they experience weight discrimination and how much it impacts their life, how likely they are to avoid medical treatment due to weight stigma, or whether they’ve been denied treatment due to weight stigma.
Okay, I hope I will be able to get my points across coherently since this is a really emotional topic for me, but in addition to what Ampersand and KellyK said I want to add two things:
(1) In terms of Covid-19 – what do you suggest fat people should do? Even if weight-loss was attainable for most people, the virus is already here. And it is not at all clear that it is a good idea for people to actively try to lose weight during the epidemic. So yeah, weight might or might not be a specific risk factor in this case (I am unaware of any studies suggesting that it is for all infectious diseases).
(2) The kind of attitude you, JFAK and Tether, are showing is exactly the kind of attitude a lot of health professionals show and which directly restricts fat people’s opportunities to care for their health. Look, I completely get that weight might at some level be an independent risk factor for some diseases. So are a lot other things. The problem is that in my experience it is almost impossible to get any health advice or to engage in any kind of assumedly professionally organized health-promoting activity like an exercise class without getting unsolicited weight-loss-advice. And that is the case even though there is no dispute whatsoever that exercise and other healthy behaviors (e.g. behaviors aimed at stress reduction, positive social interactions, etc.) are good for people’s health regardless of if they lead to weight loss or not.
KellyK:
You seem to be arguing that there are a slew of things around obesity that may contribute to greater death and hospitalization instead of the obesity itself. But there is really a mechanism (inflammation and the cytokine storm):
https://www.nature.com/articles/s41366-020-0597-4
That link is just one of lots of stuff you can find.
Regina:
I don’t think that people should be insulted or the like because of their weight. But instead of a defeatist attitude (nothing is going to work anyway, so why try), maybe something could be found to reduce weight in a safe way. Maybe it’s not as dark as is being presented here. But (this is important): If you personally don’t want to lose weight, don’t. And in that case, if you have friends who are abrasive about it and can’t accept your weight, I would get some new friends.
Tether: I believe (and appreciate!) that you mean well. The point, however, is not if something somewhere might at some point be found to effectively reduce weight. The point is that to date study after study has failed to demonstrate such a method. Even the studies that say that they have found something that works. The only method that might actually reduce weight in a large proportion of people in the long term is currently weight loss surgery. And that comes with a whole host of other problems. In light of this, I wish that researchers, doctors, psychotherapists, physiotherapist and pretty much all other health professionals would change their attitude that the best thing a fat person can do for their health is to try to lose weight.
It is okay with me to still do some research on how to people might be able to lose weight in the long term (although we might want to throw a little less money on it after all these years). However, I really, really would appreciate it if health professionals and researchers would also be open to ways how improve the health of fat people independent of weight loss.
Maybe an example will help. Some years back I made a deal with a physiotherapist in my hometown. He would train me for free and in return I would help him studying for an exam he had to take. For the most part I really profited from this deal. Plus, he was (and is!) a really nice person and I enjoyed working with him. However, one day he had me do this kind of exercise: https://www.youtube.com/watch?v=MBqyugz24Z4.
When I expressed concern that this would put of lot of strain on my knees (I weigh about 300 pounds), he said that he was sure I would not stay fat forever, so I should not worry too much about temporary strain on my joints. This is, in my eyes, exactly the kind of attitude that needs to change. Based on current knowledge, it seems very likely that most people who are fat today will not be able to achieve sustained weight loss. And health professionals should operate on that assumption.
By the way: I usually loathe comparisons of weight and drug addictions. For one, weight is not a behavior or even tied to just one specific behavior. But I believe that both, fat people and people addicted to drugs would really profit if society would adopt a perspective that (a) looks at the whole person, not at one specific trait und (b) adopt a harm reduction perspective when it comes to health. If a large number of people has been shown to be unable or unwilling to change a certain thing that might influence their health negatively, we should work with them to find ways how they can live healthier (and happier!) lives without changing that one thing.
Dear Moderator(s): My previous comment was marked as spam (probably because of the link?) and disappeared… If possible, would you please “rescue” it?
Done! Thanks for letting us know.
I doubt it was the link – people include links in comments fairly often. I never understand what makes the spam trap decide a comment is spam.
Thank you :o)
(Gah! And I totally messed up some of the sentences even though I did proofread my post)
Harm reduction is really, really un-American at this point in time. It’s simply not something that we think is valid and/or viable these days. It’s a really harmful attitude, but we see it over and over again.
J. Squid – that is an interesting point. Do you have any idea why harm reduction might be un-American at this point in time?
I am German/currently live in Germany – so my perspective is probably somewhat different. However, at least when it comes to attitudes towards body weight I do not see a lot of harm reduction approaches here either.
My guess is that political polarization mirrors the increasingly black or white view of American society. But it’s only a guess.
But we’ve refused harm reduction for weight, nicotine, drug addiction, homlessness and on and on and on. It’s the American way in the 21st century.
Has there ever been a time in American history when harm reduction wasn’t un-American?
And you seem to be arguing that minority stress and size-based discrimination don’t exist when they very clearly do. I’ve experienced it myself, I can point to a slew of examples of other people who have experienced it, I can show you piles of surveys on doctors’ negative attitudes toward their fat patients.
I’m not making the argument that there are no innate characteristics of high body weight/body fat percentage that result in worse health. I am stating that when a population is subject to bullying and harassment, viewed as lazy and inferior, and struggles to get the same medical care as their thin counterparts, it would be really naive to assume that none of that impacts health for that population, the way you’re doing.
This completely contradicts your assertion that it’s weight and only weight that’s a risk factor. They’re specifically looking at “a group of metabolically ill patients” based on a definition of obesity other than BMI. If you redefine “obese” from “has a certain body mass index or body fat percentage” to “has a certain body mass index or body fat percentage *and* has specific other medical issues,” then by definition, you’re not looking at body fat alone.
Absolutely.
I think that’s absolutely part of it. I also think a lot of it has to do with a just world fallacy and a desire to believe that people with problems are morally inferior to people who don’t experience those problems. Because if those people’s bad choices are the sole cause of their problems, it provides a safety net. You’ll never experience those problems if you yourself make good choices.
If you hold out one simple solution, whether it’s “quit being fat” or “quit using drugs,” it’s really easy to wash your hands of anybody who fails to comply with your simple solution as not trying hard enough and therefore not worthy of any help.
Harm reduction is harder, because it involves empowering people even if they’re making decisions you don’t approve of. It’s much less “do this thing to prove you’re worth helping” and much more “If you can’t do this thing, or you can’t do this thing right now, what other things *can* you do?”
At least in the context where I’ve seen harm reduction used well (crisis counseling), it also acknowledges that everybody’s situation is different and that people do maladaptive things because they’re the best tools they have access to, not because nobody has told them that those things are maladaptive.
I know it’s not statistically significant, but I was obese, lost over 100 pounds 13 years back, and have kept it off since (no medication). And it also drove diabetes completely out of the picture for me. So I don’t buy the futility argument.
Also, I have a degree in stats (albeit not biostats), and the evidence that obesity leads to bad outcomes in COVID is about as strong as for any other factor (except age). Given the difficulty of doing large scale studies in the middle of an epidemic, it’s very strong. And there are statistical reasons you can’t keep controlling for other factors, especially given the very high correlation between obesity and diabetes.
Someone asked on this thread — what should obese people do about COVID ? Well, they should realize they are in a high risk category especially if they have diabetes and take extra precautions ti avoid infection. It may be comforting to be told that obesity is not a risk factor for COVID outcomes, but it’s deceptive and positively dangerous.
We don’t say it’s ageist to point out that elderly people are at high (sometimes very high) risk from COVID. Why would we say it’s somehow inappropriate to make a similar claim for diabetes or obesity or hypertension or .. ?
After my previous post, I happened to read this article
Obesity a major risk factor for COVID-19 hospitalization
What do you think the message is for people who are currently obese, in their understanding of COVID-19?
I think the message is that you need to treat obesity seriously as a pre-existing condition that increases your risks for COVID-19. Maybe you didn’t consider that because you’re young, and thought of this as an old person thing. But no—if you’re obese and you’re 25, or 35, or 45, you have a risk factor and you should be appropriately careful.
..
If you’re substantially obese, this is the time to be prudent: wear the mask, keep a distance from others, and contact your doctor sooner than you might otherwise if you feel sick. This is your life.
I obviously agree about being prudent, wearing masks, etc..
But I’d say the same to thin people. Wearing masks is (in the current understanding) more about protecting others from being infected by you, if you’re unknowingly carrying Covid, then it is about self-protection. It’s therefore important that everyone do it, including people who imagine they’re immune because they’re young and thin.
When you say “I don’t buy the futility argument,” I’m not sure what that means. Are you saying that because of your personal anecdotal experience, you think that any fat person can have the same experience you did, and the actual studies of how well weight-loss diets work are all false?
The nice thing about reality, if you find comfort in the knowledge that hard truths will out, is that it’s not in the business of selling anything, does not care what you announce you’re willing to “buy.”
That someone was I. And I actually agree with you: Fat people should take it seriously that they are probably at a higher risk of dying from COVID-19 and use that knowledge to guide their behavior.
However, this really does not have an awful lot do with if it is a good idea to push weight loss on people. If people with a certain trait have a heightened risk for certain negative health outcomes they certainly should be informed about it.
No one here has argued that fat is not a predictor of some negative health outcomes. But first of all you cannot prove causality with observational studies alone. And second of all even if fat is really the deciding factor for the respective health outcomes and not just a correlate of other factors (which I actually do not doubt might be the case with SOME of the respective risks) that still does not mean that trying to lose weight is the best (or only!) way to mitigate those risks.
“Given the difficulty… it’s very strong.” That doesn’t make a lot of sense. If someone asked me what color the barn across the road was, and it’s dusk and there’s pouring rain, I can peer across the street and say “it looks blue, but it’s hard to be certain in these conditions, because visibility is terrible.”
What I shouldn’t do is say “it looks blue, and that finding is very strong, because there’s not going to be a better way to tell under current conditions.” You can’t hand wave uncertainties away by saying “well, under current conditions we’re not going to do any better.” Sure, report the finding – and as a fat person, I certainly do take that into account when accessing my own risks – but let’s not pretend it’s a very strong finding when it’s not.
And how is it fucking relevant here anyway, my friend? I’ve had this come up a lot on Twitter – fat-haters who respond to the evidence that weight-loss plans do not work for the large majority by saying “yeah, but fat people are more likely to die of Covid, so checkmate!” Aside from anything else, the sheer illogic of it is painful. The likelihood of successfully losing enough weight for a fat person to stop being fat is not in any way affected by if fat people like me are more likely to die of Covid. The two things are completely unrelated.
What I understood that to mean (in fact a different meaning didn’t occur to me – maybe I read it too fast), and maybe that’s what he meant, but it wasn’t carefully expressed, was that given the current difficulties, that’s some of the strongest evidence that could be obtained right now under the circumstances.
I understood him to mean that, too.
But – as I said, and I guess I’m not expressing myself well? – there’s a difference between “as strong as evidence can get under current circumstances” and “strong evidence.” The former does not mean the latter.
Amp @8
Tether @11
I think you have the causation of defeatist attitude backwards. Focusing on reducing weight causes many people to give up on healthier eating and exercise. It is more effective to focus on changing behaviors, and let go of whether weight loss results. There are a lot of positive changes that very frequently DO result when people, fat or thin, switch to healthier diets and start exercising regularly, such as lower cholesterol, lower blood pressure, more stable blood sugar levels, better muscle tone, ability to walk further and/or longer, ability to lift more… or just feeling better.
FJAK @23
I remember seeing a report on a study of people like you, and I’ve been trying, unsuccessfully, to find it. They followed people who had maintained significant weight loss for over 5 years. I wish I cold find it.
Was it a report on the the National Weight Control Registry (NWCR)?
I’m not sure if it was the NWCR. My memory of the people followed in the documentary I saw was that their whole lives revolved around maintaining their weight. That doesn’t fit with the thumbnail findings on the NWCR web site, which doesn’t seem to show any extraordinary efforts on the part of people who keep the weight off.
Interviews I’ve seen with NWCR members are pretty much what you describe – every single meal measured carefully, an hour or more of daily exercise, etc.. I don’t know if that’s representative or not, though. The NWCR definitely seems to have an agenda in how it reports, though, or at least that’s been my impression.