Ever since I started medical school, I have been told that being fat is unhealthy. That fat people are at increased risk of disease and death and because of this, it is my job to educate people about this risk and help them to lose weight. It makes sense right? Being fat is unhealthy and I want to help people, so telling them to lose weight is the ethical thing to do.
Around the same time that I qualified as a doctor, I discovered the body positive movement and I thought “Wow, Yes! This is great!” I wanted people to feel empowered and confident, not ashamed of their bodies. But, then this cognitive dissonance came. If I believe that people should love and accept themselves for who they are, does that mean I shouldn’t tell people to lose weight? Is it still fat shaming if it is coming from a medical professional? Can you help people to lose weight without shaming them? I’ve seen accounts from people who have left their doctor’s appointment feeling humiliated, ashamed and angry after being told by their doctor to lose weight. I hardly think that is an effective way to motivate people into lifestyle changes.
Added to this is the feeling of guilt I get whenever I have to discuss weight with my patients. This is because often psychiatrists are the ones who have made our patients fat. Particularly some of the newer antipsychotics (I’m looking at you – Olanzapine) make people gain a vast amount of weight in a short amount of time. Then we turn around and dump that guilt and responsibility onto our patients, lecturing them about exercise and healthy eating, pretending as though we did just give them the “make me fat” pill.
Well, I’m about to investigate these issues.
It is well documented that obesity is associated with higher risks of all kinds of diseases. A systematic review and meta-analysis of the research available in 2009 found that obesity was significantly associated with type 2 diabetes, all cancers except oesophageal and prostate cancer, all cardiovascular diseases, asthma, gallbladder disease, osteoarthritis and chronic back pain.
However, the reason why obesity is associated with these things is not yet determined; i.e. we do not understand the finer biological mechanisms that link obesity to these diseases.
Added to this, we know that despite millions of people actively dieting, with more fad diets, diet books and nutrition experts than ever before; dieting does not work. People do not tend to achieve sustained weight loss through diet and exercise alone.
In fact, we have had a better solution to weight loss for many years. It is called weight loss surgery and it is way more effective than dieting. But, it’s rarely available on the NHS.
This is absurd right? All of this talk about obesity being the cause of all these diseases. The modern day enemy of medicine. If the medical community REALLY thought that obesity was a major cause of disease and death, why would it not do everything it can to prevent it and the complications of it by offering weight loss surgery to everyone who is obese?
The reason? Systemic fatphobia.
Obesity is seen as a problem of will power, as a defect in the character of the person who is overweight and not as a disease. Society’s deeply engrained prejudice against fat people is preventing them from getting the care they supposedly so desperately need.
Well, actually, I’m not even convinced that obesity is the harmful epidemic that it is made out to be.
Firstly, what do we even mean when we say obesity? Well, the standard recognised definition is a Body Mass Index (BMI) >30kg/m². The BMI is your weight when compared to your height. In general, people who are shorter would be expected to weigh less and people who are taller expected to weigh more. But there are some real problems with using BMI as a measure of obesity. The BMI was never created for individual use; in fact it was only supposed to be appropriate for use in population studies not to track individuals. An example for why this is the case can be found in people who are extremely muscular who will often have a high BMI despite having a low body fat percentage. On top of that, many studies have shown that it is not enough to look at weight and height as well but where the fat is distributed. More detrimental effect on health is thought to occur when fat deposits on organs rather than superficially under the skin. In that case, someone with a large abdominal circumference or “beer belly” is thought to be more unhealthy than someone with equally distributed fatty tissue. This is not something reflected in a BMI measurement.
Ok, so to start off, we are using BMI as a proxy for obesity which is problematic in itself. Added to that, we are also using obesity as a proxy for poor cardiometabolic health.
Here’s the interesting thing. There are healthy fat people and unhealthy fat people. There are also healthy lean people and unhealthy lean people. A study by Guo and Garvey (2016) looked into obesity and metabolic status separately to see which one really carries the higher risk of disease. Their results are very very interesting and I would recommend reading the full paper as there were many more findings than those that I will discuss here.
This study split people according to BMI into lean, overweight and obese using the standard measures for these. It also split people into healthy, unhealthy and suboptimal metabolic health. To do this, they looked at 3 risk factors known to cause diabetes and cardiovascular disease which were high blood pressure, high blood sugar and high cholesterol. People who had all 3 factors were labelled “unhealthy”, those who had none “healthy” and those who had one or two “suboptimal health”.
They then followed these people up over 20 years and saw how their weight and disease status changed.
Starting with obesity, they found that people who were obese stayed obese. They did not lose weight and become lean. Whilst 18% of young lean people became obese, older lean people did not tend to become obese.
In terms of cardiometabolic risk factors, what they found was that being unhealthy was associated with a high risk of cardiovascular disease and diabetes regardless of weight. They also found that people’s metabolic health remained stable. If you started as metabolically healthy, you would remain healthy and vice versa. Even more significant was this finding; Metabolically healthy people with obesity are not at increased risk of cardiovascular disease and only at slightly increased risk for diabetes compared to healthy lean people but not at increased risk compared to unhealthy lean people.
So, what does this really mean?
If your risk of cardiovascular disease and diabetes is dependent on your metabolic health rather than your weight, you cannot tell someone’s health status by looking at them.
This means, you cannot continue to fat shame people using “health” as your scapegoat.
Unless you are someone’s doctor, you do not have access to the information you need to decide if someone is healthy or not. And even if you do; metabolic health is a more significant risk factor than weight.
So in the mean time, what do I do at work? I am obliged to document and monitor weight and to promote “healthy lifestyle” and weight loss. I have to fill in countless forms and document conversations about this because otherwise my trust won’t receive the money it needs to pay for the psychiatric treatments I deliver. I can’t just boycott anything to do with obesity in my job. I’ve always felt that it was hypocritical to advise people about their weight anyway. I mean, I am a lean person but I am far from healthy all the time. I am also human and I didn’t get into this job to put myself on a pedestal or lecture others about their life choices.
Well I don’t have all the answers I’m afraid and I’m hoping the system will change. In fact, I will actively use my voice to speak out against it.
Until then, what I can do is to listen to my patients; understand what their relationship with food is like, how they view themselves and their health. I can explain the facts as we know them; explain the current guidelines, the evidence behind them and any new evidence we have. What I can do is support my patients and listen to them. By fat-shaming, we ensure that people feel guilty and ashamed and what’s worse, we damage the therapeutic relationship we have with them. What is most important is that, regardless of your weight, you are a living being, worthy of compassion, worthy of respect and worthy of dignity.