Image Text: What would fat people's health outcomes look like if we weren't constantly subjected to whatever "interventions" the diet industry thought would make them money Let's find out. Gary Taubes recently wrote a piece called "How a 'fatally, tragically flawed' paradigm has derailed the science of ob*sity" in which he congratulated himself for debunking bad science around fatness while... wait for it...promoting bad science around fatness.
Before I get too far into this I want to be clear that, while I think it's important to talk about the science because it's (mis)used to harm and abuse fat people, that should never detract from the fact that it's fine to be fat no matter what, that adding healthism to fatphobia does not make either ok or justifiable, and that fat people have the right to live without shame, stigma, bullying or oppression no matter why we are fat, no matter what the "health impacts" might be, and whether or not we could, or even want to, become thin. That includes the rights to equal accommodation, including in healthcare.
So, let's talk about this article. He starts out by saying, correctly, that fatness is not just about a "calories in, calories out" equation. (I wrote a blog post about this called The Calories In/Out Myth in 2011, which cited the work of just some of the people who have been talking about this since long before that, but I guess...welcome to the party Gary?)
Gary is correct that the calories in/out paradigm is deeply flawed (and is still being widely used, including the absurd medical "diagnosis" of fat people as "ob*se due to excess calories" by doctors who have never even asked about calorie consumption. This is driven by weight stigma which is fundamentally linked to racism and anti-Blackness (resources around this include Sabrina Strings Fearing the Black Body: The Racial Origins of Fatphobia and Da'Shaun Harrisons Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness)
The tragic flaw comes in the next leap of logic, in which Gary suggests that while fatness isn't caused by a calories in/calories out equation, it's still about what fat people eat, being fat is still something that should be pathologized and medicalized, and we should still push for the eradication of fat people. Let's take a look
[Note, the quotations include harmful language, including terms that were created to pathologize and medicalize fat bodies, and may be triggering - you can skip them and still get main points of this piece]
I might have embraced this thinking as well if the prevalence of ob*sity had not risen relentlessly for the past half century; if ob*sity - along with type 2 diabetes, its partner in pathology - had not become the dominant non-Covid health crisis of our time. But I can't...
Regular readers will know that I am an alliteration super stan, so I want to give him at least some credit for for "partner in pathology." But I can't.. because this concept is so harmful and wrong. The article does a decent job of debunking the "calories in/calories out argument" (but since people have been doing that for literally decades, including in Fat Activist and Health at Every Size circles, I can't give him much credit for that either) Blaming fatness and calling it a health crisis without examining (or even mentioning) t he impacts of weight stigma, weight cycling, and healthcare inequalities on the wellbeing of fat people is bad science that drives more weight stigma, weight cycling, and healthcare inequalities.
So Gary is late to the party on calories in/calories out, but at least he is here, right? I mean at least he's being clear that being fat isn't something to blame on what fat people eat...
People don't get fat because they eat too much, consuming more calories than they expend, but because the carbohydrates in their diets - both the quantity of carbohydrates and their quality - establish a hormonal milieu that fosters the accumulation of excess fat...
Oh. Never mind. He's just pitching another "it's what they eat" claim. How can this account for the fact that people can eat the same things and be vastly different weights, and that people can eat different things and be the same weight? Gary's has an answer there to...sort of...
Since not everyone is ob*se or overw*ight, some people clearly do balance their intake to their expenditure even in an environment where food is everywhere. Shouldn't a viable hypothesis of ob*sity be able to explain why some people remain lean and others don't without implicitly or even explicitly blaming character?
This problem is solved by simply defining ob*sity as what it clearly is: a disorder of excessive fat accumulation.
I had to take a minute to bang my head on my desk, but I'm back. If you're touting a paradigm that pathologizes fat bodies, I can see how it's convenient for you if we all just accept that fat bodies can be pathologized because they are fat, but, I can't back you on it for reasons I'm about to discuss, as well as the fact that people with the same weight/amount of fat have vastly different health statuses.
And here's where this all goes, arguably, the most (tragically) wrong.
The undeniable evidence is the enormous increase in the prevalence of ob*sity worldwide. In the U.S., 12% of Americans lived with ob*sity 60 years ago; more than 40% do today. Something has changed in the environment - in diets or lifestyles - to trigger such a dramatic rise in the prevalence of ob*sity. But is it nature or nurture that the environment triggers, behavior or physiology, minds or bodies?
In this paragraph he is almost there, but then he takes that left turn at weight stigma. In order to rush to his preferred way to pathologize fat people, Gary blows right by the possible answers to his own question. What has changed?
Well, for one thing, in 1998 (driven by the weight loss industry) the definition of "ob*sity" was lowered, impacting the weight classification of tens of millions of people. I wrote about that here and I'm just one of many, many people who have pointed this out. If you are talking about the so-called increase in fatness without mentioning that, I feel like it calls your methods and intentions into some serious question.
The other thing that has changed is the advent of the weight loss industry (or, more correctly, the weight cycling industry, but we'll get to that.). Intentional weight loss products and programs started to become commercially popular in the 1930's, became even more popular post WWII, and have steadily grown since. The industry has grown to $71 BILLION dollars a year (up from $20 billion dollars in 2012 alone.)
Why is this important? Because intentional weight loss attempts (whether we're calling them diets, lifestyle changes, health plans, or something else) end up in weight regain about 95% of the time, and up to two-thirds of those people gain back more than they lost. And the advice those people are given is...try again! (The industry has brilliantly taken credit for the first part of the biological response (weight loss) and blamed their clients - and convinced their clients and everyone else - to blame themselves for the second part of the biological response, which is the only way that they could have seen such exponential growth with a product that fails almost all the time and has the opposite of the intended effect the majority of the time.)
Put plainly, tens of millions of people were made fatter by definition literally overnight in 1998, and intentional weight loss attempts predict weight gain, and they have been prescribed to more and more people, at younger and younger ages, since the 1930's (and those are just two of the possible reasons that people might be a bit bigger in the past - there's also life changing/saving medications that cause weight gain and a myriad of other reasons.) But Gary doesn't think that's worth mentioning in his discussion of the possible reasons that people are fatter. Again, there is nothing wrong with being or becoming fat(ter), but there is something deeply wrong with not just putting such a focus on why people are the size they are, but then also ignoring the fact that the thing that anyone bigger than the (racist, diet-industry-driven) standard of "normal weight" is told to do most often results in weight gain and health issues, which we'll talk about momentarily.
In truth we have no idea what people's sizes or health statuses would be if we didn't try to manipulate fat people's bodies with weight loss attempts, often from childhood, and we will never get to find out if people remain myopically focused on eradicating fat people instead of supporting our health in the bodies we have.
So, the most common outcome of intentional weight loss attempts is weight regain. And the most common advice to those who experience this is to try intentional weight loss again (and again, and again.) This results in weight cycling (aka yo-yo dieting) and weight cycling, Gary conveniently leaves out of his article, may also be the driver of the health issues that he is so quick to assign to fatness.
Bacon and Aprhamor covered this (and much more) in their paper "Weight Science - The Evidence For A Paradigm Shift"
Consider weight cycling as an example. Attempts to lose weight typically result in weight cycling, and such attempts are more common among ob*se individuals [ 62]. Weight cycling results in increased inflammation, which in turn is known to increase risk for many ob*sity-associated diseases [ 63]. Other potential mechanisms by which weight cycling contributes to morbidity include hypertension, insulin resistance and dyslipidemia [ 64]. Research also indicates that weight fluctuation is associated with poorer cardiovascular outcomes and increased mortality risk [ 64- 68]. Weight cycling can account for all of the excess mortality associated with obe*sity in both the Framingham Heart Study [ 69] and the National Health and Nutrition Examination Survey (NHANES) [ 70]. It may be, therefore, that the association between weight and health risk can be better attributed to weight cycling than adiposity itself [ 63].
Similarly, to connect fatness with diabetes without pointing out the ways that dieting has been correlated with insulin resistance and type 2 diabetes is disingenuous at best. Even though they are still coming from a flawed weight loss paradigm, even the American Diabetes Association points out that weight cycling and insulin resistance and type diabetes are linked, including that a 2017 study in The New England Journal of Medicine found that people who experience weight cycling were 78 percent more likely to develop type 2 diabetes over a period of about five years compared with those whose weight remained more constant.
Peter Muennig's work also found a link between the stress of constant weight stigma type 2 diabetes.
What would happen if we stopped trying to eradicate fat people? What would fat people's health outcomes look like if we weren't constantly subjected to weight stigma, weight cycling, healthcare inequalities, and whatever "intervention" the latest person who was trying to profit from weight stigma decided to cavalierly foist upon the general population of fat people, without any evidence of long-term efficacy in either creating thinness or greater health (which are two different things.). We don't have a clear answer to that, but we have some signs.
Studies like Matheson et. al., and Wei et. al. show that (understanding that health is not an obligation, barometer of worthiness, or entirely within our control,) behaviors are a much better predictor of future health than body size. Peter Muennig's study found that cis women (unfortunately, as is all too common, there was no trans or nonbinary representation) who felt good about their size had less physical and mental illness than cis women who felt they were too large, regardless of their size (with the understanding that the blame isn't on those who had internalized the weight stigma that is all around them, the problem is that the weight stigma exists)
And Tylka et. al. also looked at this comprehensively, concluding
The weight-normative approach is not improving health for the majority of individuals across the entire weight continuum. Weight is overemphasized for higher-weight individuals (i.e., assumptions are made that they are unhealthy) and underemphasized for lower- or "average-" weight individuals (i.e., assumptions are made that they are healthy). Furthermore, we know that weight loss through dieting is not sustainable over time for the vast majority of higher-weight individuals and is linked to harmful consequences. Therefore, we argue that it is unethical to continue to prescribe weight loss to patients and communities as a pathway to health, knowing the associated outcomes-weight regain (if weight is even lost) and weight cycling-are connected to further stigmatization, poor health, and well-being. The data suggest that a different approach is needed to foster physical health and well-being within our patients and communities.
Advocates of a weight-inclusive approach assert that we are acting on behalf of our patients' and communities' interests when we centralize health for people at all points along the weight continuum and work to eradicate weight stigma in all settings, including health care and public health. This paper has reviewed the data in support of a weight-inclusive approach to foster physical and psychological well-being. We encourage both scholars and practitioners to study and document what happens when health professionals and their target populations shift their focus to developing sustainable healthy behaviors for every body.
Whipping people up into a frenzy about an "ob*sity epidemic" is highly profitable, and can be a way to get attention, but it doesn't actually do anything helpful or good. As I have said before, we can solve the "ob*sity epidemic" right this minute in one simple step - just set the whole concept down and move to a paradigm that respects and supports bodies of all sizes.
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