FAT SHAMING

Is obesity really that bad for you?

Big, bold and body-positive. Growing calls for “fat acceptance” fly in the face of medical advice, but is being overweight actually that bad for your health.

Women's glossy magazines often get flak for promoting unhealthy beauty ideals, but usually it is because their models are so thin. Not so for this month’s UK issue of Cosmopolitan, which features the plus-sized model Tess Holliday resplendent in green satin underwear.

Holliday’s success in modelling, despite her UK size-26 figure, epitomises the burgeoning “body-positive” movement, which says that people’s weight is their own business and that no one should dislike the way they look.

“If I saw a body like mine on this magazine when I was a young girl, it would have changed my life,” Holliday said when she posted the cover on Instagram.

Yet there may be downsides to this idea of “fat acceptance”, as it is sometimes called. Doctors want to warn people about the physical risks of being overweight – not only for the sake of their personal health, but also because of the wider impact on medical budgets. So does fat acceptance mean we face a clash between people’s health and their happiness? And if so, which should take priority?

This is an issue that goes beyond one magazine cover, as almost all countries are seeing rising numbers of their citizens classed as overweight. Obesity is the top public health problem facing most Western nations.

We have long known that being significantly overweight comes with certain health risks, such as a higher rate of heart attacks. More recently, we have found that just being moderately overweight makes people more prone to developing diabetes, which can lead to complications such as foot amputations and blindness.

As a result, people who are overweight often face a lecture from their doctor about slimming down, even if they are visiting for unrelated reasons. Some UK family doctors now advise their patients to use commercial weight loss programmes, like Weight Watchers.

Wider society is also adopting an increasingly moralistic tone about health and fitness. Earlier this year, UK magazine The Big Issue urged readers to take a “health pledge” to exercise and take better care of themselves to avoid “being a drain” on the National Health Service.

“There’s an atmosphere where it’s OK to publicly criticise overweight people,” says Margaret McCartney, a doctor in Glasgow, UK. Cosmopolitan was admonished by both internet trolls and TV journalist Piers Morgan for promoting unhealthy eating when it put Holliday on the cover.

But can we be so certain about the health toll? Take the current campaign from the charity Cancer Research UK (CRUK), with ads depicting chips like cigarettes in a packet. The charity says that obesity is a cancer risk comparable to smoking, and that in future the risk from obesity may be greater.

Sofie Hagen, a comedian who founded a Danish fat-acceptance organisation, says such campaigns aren’t justified by medical evidence. The studies cited by CRUK show correlations between being overweight and a higher risk of certain cancers, but not that being overweight causes those cancers. Something else might underlie both, such as lack of exercise or being poor.

Even if being overweight really does cause cancer, it doesn’t play a particularly big role. According to CRUK’s own figures, obesity is linked to just 6 per cent of tumours. The ad campaign could leave cancer patients thinking they are to blame for their illness when they aren’t.

Cancer isn’t the only health risk from being overweight. But the wider health consequences of obesity, such as increased risk of heart disease and diabetes, are not always as dramatic as the health warnings suggest.

One study found that people in their 60s and 70s who have a body mass index (BMI) of over 30 – classed as medically obese – lose just one extra year of life on average. The size of the effect is larger for those who are younger because they have more life left to lose, so if you are obese in your 20s and 30s you lose about six years of life.

It isn’t just about lifespan, of course, but also the extra toll on health while people are still alive. Obese people in their 20s lose about 13 years of healthy life, while very obese people of the same age lose about 19 years, compared with those of recommended weight.

Costly calories

Those extra years spent in poor health cost health services money. As such, many argue that public health bodies should warn people about the medical consequences of being overweight.

That said, there are other behaviours that are likely to cost health services money – such as parachuting – that don’t attract the public vitriol reserved for being overweight. Being lonely correlates with higher rates of heart disease too. Sure, no one chooses to be lonely, but then no one chooses to be fat either.

There is another flaw in telling people to lose weight. It ignores the fact that there is no simple way to achieve this long-term. The exact figure is unclear, but most people who go on a diet put the weight back on and often end up even heavier than when they started. According to one study of people following the Weight Watchers programme, just one in five were still at their goal weight two years later.

Why is it so hard to keep it off? When someone loses any significant amount of weight, their body goes through several changes. Hormone shifts mean people feel hungrier than they used to after a set amount of food. Their metabolism slows, so the same calorie intake that previously kept weight steady now piles on the pounds, says Traci Mann at the University of Minnesota. “It doesn’t make it impossible to keep the weight off, but it makes it harder.”

The only weight loss method shown to work long-term is gastric surgery, where the stomach or gut is made smaller. But surgery is a drastic measure, with the operation itself carrying risks. In many countries, it is restricted to people who are morbidly obese.

What can everyone else do? There is another way, says Mann: work towards improvements in health, not weight. If people can adopt a healthier lifestyle, they should see improvements in their blood pressure and blood sugar levels, making heart disease and diabetes less likely, even if they don’t lose weight. “Exercise has benefits even if you don’t lose 1 pound,” says Mann.

Such an approach clashes with the belief that anyone who is overweight must be unhealthy, but there is growing evidence to suggest that isn’t true. Certainly, people who are overweight are more likely to have high blood pressure, cholesterol or blood sugar – but not all do. By some estimates, as many as a third of people who are overweight have good scores on these measures. Doctors should switch from recommending weight loss to advising people about exercise and healthy eating, says Mann.

Fat acceptance campaigners such as Hagen say it is not even ethical to tell people to diet. “I don’t know a single fat person who hasn’t been on a diet. I have tried that the majority of my life. Why not work with the body I have now?”

But Yoni Freedhoff, who heads the Bariatric Medical Institute in Ottawa, Canada, says fat acceptance groups become dangerous when they dismiss dieting. “They say it’s impossible and unnecessary to lose weight. That [ignores] the challenges to the quality of life of individuals who are dramatically obese.”

While Freedhoff accepts that significant weight loss is rare, he says the effort is worthwhile for those who do manage it. And a sizeable minority succeed in losing and keeping off more modest amounts, such as 5 to 10 per cent of their starting weight, which can be helpful. “I have seen people who have lost 5 per cent who have come off various medications,” says Freedhoff.

Clearly, any decision to try to lose weight has to be an individual one, taking into account people’s past attempts, current health status and their personal feelings.

What frustrates Hagen is that while commenters may couch their criticisms as health concerns, she suspects they really just enjoy judging and finger-wagging. “People hate fat people and they fear becoming fat – it’s the worst thing you can be.”

But personally, she has had it with strangers offering her medical advice over the internet. “I don’t owe anyone my health. It’s my body.”

Written by Clare Wilson in "New Scientist", UK, 29, September, 2018,vol.239 n. 3197, excerpts 20-21. Digitized, adapted and illustrated to be posted by Leopoldo Costa.