Science

In Obesity Research, Fatphobia Is Always the X Factor

“Tell me what I’m missing,” my husband said. He, like many of us, had seen headlines about a recent study that surveys the weight, exercise habits and cardiovascular disease risk of over half a million people in Spain. It’s being covered by media outlets as irrefutable proof that no, sorry, forget what the body positivity movement has told you—you cannot be both fat and fit. This is not a new argument. It’s the comment made on every story I write, as a journalist who covers weight stigma (negative beliefs about large bodies that lead to discrimination against fat people). But in a burst of good news for internet trolls, the authors of this new study, who published their findings as a research letter in the European Journal of Preventive Cardiology, drew this same conclusion because the people in their study with high BMIs had a higher risk of diabetes, hypertension and high cholesterol than the people with body mass index scores in the normal rage.

This relationship stood even when people in bigger bodies exercised regularly. Therefore, “weight loss per se should remain a primary target for health policies aimed at reducing CVD risk in people with overweight/obesity,” the researchers wrote. So, what’s missing from that conclusion, and this argument more broadly? Any acknowledgment of the way weight stigma (also known as fatphobia) impacted the study’s design, the health of the participants, and our entire understanding of weight and health.

Let’s start by noting that these conclusions contradict several other recent pieces of research. A 2017 study published in the same journal followed 5,344 Dutch people over the age of 55 for 15 years and found that folks with high BMIs who also had high levels of physical activity showed no increased risk for heart disease compared to equally active people with normal BMIs. An analysis of data on 22,476 Americans aged 30 to 64 published in 2020 found that being physically active was associated with a larger reduction in a person’s 10-year heart disease risk than having a normal BMI. Both of these studies affirm the conclusion drawn in a 2014 meta-analysis of 10 studies that when it comes to mortality risk, fitness matters more than fatness.

But when researchers talk about these findings, they call them “the obesity paradox,” because it’s so startling to see fat people not dying of heart disease like we’re always told they will. “The term ‘obesity paradox’ is a prime example of weight stigma in the scientific literature,” Jeffrey Hunger, an assistant professor of social psychology at Miami University of Ohio told me when I wrote about medical weight stigma for the July 2020 issue of Scientific American. “Think about it: A paradox is something contradictory or seemingly absurd. This term came about because it was considered absurd that fat people could actually be healthy.”

Weight stigma also shows up in the questions that researchers don’t ask. In the new study, researchers took the participants’ weight and health histories from medical records and asked them to self-report their activity levels. They did not track other established risk factors for heart disease, like diet and smoking history. And they did not ask any of the participants whether the doctors examining them displayed signs of weight bias, even though we know from other research that many doctors discriminate against patients in large bodies.

In one survey, 24 percent of physicians admitted they were uncomfortable having friends in larger bodies, and 18 percent said they felt disgusted when treating a patient with a high BMI. You are unlikely to improve the health of someone you find repulsive, and indeed, we see that doctors tend to undertreat, overtreat or even misdiagnose patients in bigger bodies, confusing tumors for fatness. And fat people are more likely to avoid medical care when they know they’ll be treated badly, which means they are often sicker and harder to treat by the time they do see a doctor.

The researchers also did not ask their high-weight participants how the experience of fatphobia impacts their ability to be physically active in the first place. Can they find workout clothes that fit? Can they go to their local gym, or for a walk in the park, without fear of harassment? In her memoir Happy Fat, comedian Sofie Hagen recalls standing in a changing booth at her gym for 45 minutes, working up the courage to walk to the pool in her swimsuit and endure the stares of other slimmer swimmers. “Gyms are for thin people, staying home and eating chips is for fat people,” she writes. “So for a fat person, going to a gym, or running in the park, or doing exercise in a place with people, can be anxiety-inducing because you are so on display doing something that is considered uncharacteristic.”

Last, the researchers did not consider whether the increased risk for heart disease found in their fat-yet-active subjects might be due to the experience of living in that fat body, rather than the fat itself. A 2016 analysis of data collected from over 21,000 Americans found a significant association between a person’s experience of weight stigma and an increased incidence of heart disease, stomach ulcers, diabetes and high cholesterol even after researchers controlled for their subjects’ socioeconomic status, physical activity level and BMI. Other studies have shown that experiencing weight stigma consistently raises our cortisol levels and other physiological stress responses, which are tied to negative health outcomes.

But here’s something the Spanish researchers find, despite their conclusion that you can’t be fat and fit: Being physically active reduced a person’s risk of heart disease compared to the less active people in their same weight class. So, a fat person who exercises may still be more likely to get diabetes or high blood pressure than a thin person, but the gulf is less enormous. (In fact, the study found that active people in the overweight BMI range had roughly the same risk for hypertension as inactive people in the normal BMI range.) More importantly, active fat people are less likely to get those conditions than if they didn’t exercise at all. This means that you can still improve your health through physical activity even if you don’t get skinny in the process. Which you probably won’t; that’s why so many of us have likely abandoned New Year’s weight loss resolutions. “To give the impression that changing your weight status from obese to overweight or normal weight is this straightforward, easy thing to do is to effectively ignore 50 years of research,” says Marlene B. Schwartz, director of the Rudd Center for Food Policy and Obesity at the University of Connecticut.

That research usually gets ignored because weight loss sells. The diet industry was valued at $192.2 billion in 2019, according to a report by Allied Market Research. Weight loss pharmaceuticals alone accounted for nearly $1.7 billion last year, according to another recent report. These industries, along with food manufacturers, have long funded much of the science that gets done on weight and health. And independent reviews, including a 2018 meta-analysis, have found that industry sponsorship influences research agendas. ‘

The National Institutes of Health’s decision in June 1998 to expand the obese and overweight categories on the body mass index to include 29 million more Americans preceded the FDA approval of two popular weight loss drugs, Orlistat and phentermine. In February, researchers at Northwestern University reported findings that semaglutide, a medication taken as a weekly injection, resulted in significant weight loss. The drug is currently marketed at a lower dose as a diabetes treatment and retails for around $1,000 a month; its potential for profit as a diet drug is enormous, especially because patients will have to take it for the rest of their life to avoid regaining weight.      

When we define health and fitness exclusively through the prism of someone’s pants size, we ignore the myriad of other measurements that matter more. Exercising regularly can build strength and flexibility, while reducing symptoms of anxiety and depression, and it improves biomarkers of health like blood pressure and cholesterol—and that’s just the start of the list. If people feel like they’ve failed at exercise because they didn’t also get smaller, they’ll miss out on all of its other benefits. And when obesity researchers and doctors keep pushing people towards weight loss as our “primary target” for health, what they’re really saying is that those other health benefits don’t matter; that our bodies will never be good enough; that we’ll never be good enough—unless we get thin. When researchers—or doctors or your mother or internet trolls—say “you can’t be fat and fit,” what they really mean is, “you can’t be fat and thin.” This is true. But it also shouldn’t be the goal.

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