But What About Your Health?
By Marilyn Wann
From Fat!So? Because You Don't Have to Apologize For Your Size [Ten Speed Press, 1998]It’s a reasonable question, after all. I want to be healthy, you want to be healthy, everybody wants to be healthy. Duh.
But being healthy is not the same thing as being thin. A long life is not determined by a number on a scale. If it were, it’d be so great to be thin, ‘cause you’d never get sick, and you’d never die. Now I am willing to grant thin people certain privileges—wearing lime green miniskirts for the one minute they’re in style, getting to date people like Donald Trump, being too small to donate blood—but immortality? I don’t think so.
The question remains, though. What about all those dire predictions of death and disease for anyone who weighs more than a flight attendant? Isn’t it unhealthy to be fat?
Of course it’s unhealthy to be fat.
If you’re fat, you’re going to have a rough time getting health insurance. You probably won’t get regular checkups and preventive care, and any health problems you might have (completely unrelated to your weight) will be a lot worse whenever you finally do see a doctor.
Even if you have health coverage, you probably avoid going to the doctor if you’re fat. So you’re in the same situation. Why do you avoid going to the doctor? Every time you walk into a doctor’s office, the first thing they want you to do is step on a scale. Then you get the lecture, or the belittling remark, or worse, the weight loss advice. You figure, as long as you feel okay, why risk it? You don’t pay for abuse in any other setting, right? You value your mental health, so you stay away.
If you’re fat and you do visit the doctor, he or she might decide to treat your weight, rather than your symptoms. You get a diet, rather than a diagnosis. The doctor says all your ills are caused by your fat. Six months later, you still have sharp pains in your heel or nasal congestion or shooting lights in your vision. So you find a new doctor. This time you actually get treatment for your plantar fasciitis or your sinus infection or your brain tumor. (These examples are based on actual cases.)
Your doctor may not like fat people. A recent study found that fat women are a third less likely to get breast exams, gynecologic exams, or Pap smears. An exception: Fat and thin women get mammograms equally often. (The authors said that doctors may do exams more readily if they don’t have to touch fat patients.) Fat women are at increased risk for certain scary cancers (breast, cervical, endometrial, ovarian). Getting less preventive care, researchers concluded, may "exacerbate or even account for" this increased risk. It’s not the fat that kills us, it’s the fat hatred.
If you’re fat, you face discrimination in all areas of society, not just the doctor’s office. Studies have found that people who face even one incident of discrimination report more chronic health problems and depression than people who weren’t mistreated. No research has been done to document the effect of lifelong mistreatment on the health of our ninety-seven million beautiful fat sisters and brothers, but that stress is there, and seeking medical help doesn’t necessarily make things any better.
If the medical industry really cared about the health of fat people, doctors would be more interested in wellness than weight loss. Their diagnostic equipment—everything from blood pressure cuffs to MRIs—might be designed to fit fat people, too. But isn’t weight loss the same thing as wellness? you’re wondering. Isn’t it, after all, unhealthy to be fat?
I get asked this question a lot. So, even though I don’t have a degree in science and am just a lowly health journalist, I scampered over to the local, world-class medical school and spent some time in the library there, catching up on all of the same studies that the medical handwringers and highly paid advice gurus are reading. I learned some lingo, attended some conferences, and I actually came to distrust a lot of the long-cherished beliefs about the health of fat people.
Then, on January 1, 1998, the New England Journal of Medicine came out with an editorial entitled, "Losing Weight—An Ill-Fated New Year’s Resolution." In it, the Journal’s editors, Jerome Kassirer, MD, and Marcia Angell, MD, refuted all of the same beliefs that I had come to question. Huzzah! So you don’t have to take it from me. The chart below lists all the things the New England Journal of Medicine itself says doctors don’t know yet.
| What I’ve Suspected All Along | What the New England Journal Says |
| We don’t know why fat people are fat. | The editors caution against seeing fat people in medical terms "rather than as ordinary people who happen to be heavier than average, probably from some mix of nature, nurture, and choice." |
| We don’t know how to make fat people permanently thin. | "Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the vast amounts of money spent on diet clubs, special foods, and over-the-counter remedies, estimated to be on the order of $30 billion to $50 billion yearly, is wasted." |
| We don’t know whether making fat people thinner will make them healthier. | "Even granting the existence of an association between increasing body weight and higher mortality, at least for younger people, it does not follow that losing weight will reduce the risk. We simply do not know whether a person who loses twenty pounds will thereby acquire the same reduced risk as a person who started out twenty pounds lighter. The few studies of mortality among people who voluntarily lost weight produced inconsistent results; some even suggested that weight loss increased mortality." |
| We don’t know if weight loss itself is unhealthy. | "To add injury to insult, the latest magical cures are neither magical nor harmless." |
| We don’t even know for sure that being fat is unhealthy. | "Given the enormous social pressure to lose weight, one might suppose there is clear and overwhelming evidence of the risks of obesity and the benefits of weight loss. Unfortunately, the data linking overweight and death, as well as the data showing the beneficial effects of weight loss, are limited, fragmentary, and often ambiguous." |
| We don’t know whether the health problems commonly associated with being fat are actually caused by the fat, or whether they’re caused by factors that go along with being fat, stuff like yo-yo dieting, poor health care, the stress of being targeted by prejudice, low self-esteem, prolonged exposure to double-knit polyester, and so on. | "Many studies fail to consider confounding variables, which are extremely difficult to assess and control for in this type of study. For example, mortality among obese people may be misleadingly high because overweight people are more likely to be sedentary and of low socioeconomic status." |
| We don’t know the long-term health risks of dieting, diet pills, or weight-loss surgeries. | Actually, based on all the medical literature, we do know some of the long-term health risks of these practices. They should be enough to warn any sensible person to avoid them. Who wants to risk gallbladder disease, osteoporosis, lowered libido, depression, anemia, hair loss, weight gain, eating disorders, loss of essential nutrients, deadly lung disease like primary pulmonary hypertension, valvular disease of the heart, gangrene of various internal organs, liver failure, and death? |
We don’t know, we don’t know, we don’t know.
What we do know for sure is that there’s a $40 billion diet industry in this country, and its health depends on Americans’ desire to lose weight. If the diet industry can’t hook you with their look-better-in-a-swimsuit argument, they’re not above threatening you with poor health or paying a few "obesity" researchers to proclaim (based on data the New England Journal calls "limited, fragmentary, and often ambiguous") that being fat is a death sentence. Yeah right, doctor. The New England Journal’s landmark editorial was accompanied by a study on body weight and longevity. In that study, researchers found no correlation between increasing weight and decreasing lifespan (in other words, the fat people were no likelier to die younger), with one exception. As obesity [sic] "experts" were quick to point out, the group of people in the study who were the fattest had double the risk of death. That’s no reason to panic. This particular group of fat people had about a 5% death rate, versus the 2% death rate of the comparison group. That’s hardly a death sentence. I’m tempted to say "big whoop" and remind you that inequities in the health care of fat people (or any other number of factors) could easily account for this small variation in death rates. Instead, let me put the statement that fat people are "twice as likely" to die into perspective. Medical studies will also tell you that men who smoke are twenty-two times more likely to die—from lung cancer—than men who don’t smoke. (Which is worse for you? Being fat or being a smoker? How many people do you know who won’t quit smoking because they fear gaining weight?) Per mile traveled, people who ride motorcycles are sixteen times more likely to die in a crash than people who drive cars. And people who live in Los Angeles have a death rate 26 percent higher than people who live where there’s little air pollution. So what if you’re a fat, hog-riding smoker in LA? Keep in mind that statistics that apply to groups of people are notoriously slippery when applied to individuals. There are no guarantees.
For fat people, I would argue that, beyond eating good food and getting regular exercise, skepticism is a key ingredient to health.
There can be no finer example of such skepticism than the work of Glenn Gaesser, PhD, a thin fellow and all-around nice guy who is an associate professor of physiology at University of Virginia and author of Big Fat Lies: The Truth About Your Weight and Your Health. Gaesser reviewed all of these medical studies about fat and health, and he came up with some startling insights into the popular beliefs.
Popular Health Myth: Fat is a death sentence.
After reviewing all of the medical studies that tracked death rates and weight, Gaesser found that fully three-fourths of them did not support the belief that the thinnest people live the longest. These studies either found that weight was not a very good way to predict how long someone will live or that, in some cases, the fatter people lived the longest.
Popular Health Myth: Being fat causes heart disease.
First of all, there’s a big difference between correlation and causation. But we can set aside that important point, because, as Gaesser’s review of all the medical literature on this topic revealed, there is no correlation between body fat and atherosclerosis, the build-up of fatty plaque in the arteries. Clogged arteries are the leading cause of death for Americans, yet after more than five decades and tens of thousands of autopsies, the studies show that fat people are no more likely than thin people to have clogged arteries.
Popular Health Myth: Being fat causes diabetes.
Admittedly, people who get adult-onset diabetes are often fat. However, losing weight is not necessarily the answer for such people. Treatment centers have found that when diabetics improve their diet and exercise habits, they can lessen the severity of their diabetes and even normalize their blood sugars. These health improvements happen even though the people who change their diet and exercise habits don’t lose any weight at all. (Gaesser cites such results from noted programs like the Pritikin Longevity Center and Duke University.) In fact, based on his review of current research, Gaesser says most people can rely on good diet and exercise to normalize such health problems as high blood pressure, high cholesterol, and insulin resistance—without losing any weight.
Popular Health Myth: Still, fat people can’t be healthy.
My absolute favorite piece of research about fat and health comes from the Cooper Institute for Aerobics Research, the nation’s leading authority on fitness. The Cooper Institute’s ongoing study of a whopping 30,000 people has found that those who are the fittest live the longest, no matter what they weigh. Fat people who exercise regularly live longer than thin people who don’t. Or, as director of research Steven Blair says, "If you are a couch potato, being thin provides absolutely no assurance of good health, and does nothing to increase your chances of living a long life."One other study about longevity is dear to my heart. David Weeks and Jamie James researched people who defy convention, in their book Eccentrics: A Study of Sanity and Strangeness. To their surprise, they found that eccentrics enjoy unusual longevity. So if believing that fat people can indeed lead long, healthy lives makes you eccentric, I say go for it!
Popular Health Myth: You can lose weight if you try hard enough.
By now, it should occur to you that this myth has little to do with concerns about health and everything to do with gaining thin privilege. In our culture, we currently believe that if you do everything "right" (spend hours in the gym, eat only brown rice, broccoli, and chicken breasts), you will be rewarded with a so-called perfect body. If you can just achieve this perfect body, you don’t just get all sorts of societal goodies, you also get the bonus of perfect health. (And if you never step on a crack in the sidewalk, nothing bad will ever happen to you.)
A whopping 95% of the people who lose weight on diets gain back every pound within three years, according to a study reported in the International Journal of Obesity. Other researchers have found failure rates for diets as high as 98%. The NIH gives diets a 90% failure rate. A very few university-based diet programs have managed to document three-year maintenance of weight loss for 15% of their participants, but that’s still an 85% failure rate, not great odds. One researcher (who believes in dieting) decided to compile a database of successful dieters nationwide. Of the seventy-one million Americans currently on diets, only a few hundred are in this database, despite the fact that its definition of successful dieting is far from rigorous. To qualify as a successful dieter, someone may have lost as much as 100 pounds, and must have kept at least 30 pounds off for five years. That’s a success? If I had gone through the extreme ordeal of losing 100 pounds, only to gain 70 pounds back, I don’t think I would consider that endeavor a success in any sense.
Given that diets don’t work, weight-loss zealots now claim that getting thin is just a matter of eating right and exercising. While these practices will indeed improve a person’s health, they will not turn 270-pound me into 110-pound Kate Moss. Nor would I want them to. Healthy habits should not result in emaciation.
Faced with the failure of dieting, the public was willing to try diet pills like fen/phen. We now know these drugs had some serious and potentially deadly side effects. Diet pill users risked death to lose, on average, only about 10% of their initial weight. Whatever new drugs come out to replace fen/phen, I question whether the unforeseeable risks can ever outweigh the alleged benefits.
After trying diets and pills, some people, desperate to escape the mistreatment and hassles they face on a daily basis, decide to submit to weight-loss surgery. I really do understand why someone would consider this extreme option. The stigma attached to even the slightest amount of body fat can be daunting, and the surgeon’s sales pitch can be very slick. However, as far as I’m concerned, weight-loss surgery is a mutilation of healthy body parts. It is never justified. Besides, it doesn’t work. In real life, most survivors of this surgery do not keep off whatever weight they lose. Often, the only permanent results are grim, lifelong side effects, including dangerous and hard-to-treat vitamin deficiencies. When someone comes at you with a knife, the healthy choice is to get away from them as quickly as possible.
Why would any doctor recommend a treatment that fails 90% of the time? Why would doctors persist in prescribing a treatment that is such a complete failure, when the health benefits of weight loss, and the health risks of being fat, are far from established? (Even the most experimental of cancer treatments are expected to have at least a 50% chance of success. And such treatments are only used on terminal patients who have no other options, not on healthy people.) Why do doctors feel justified in telling patients to lose weight when they know there is no known method of turning fat people into thin people? I can only think the reasons behind this weight-loss-at-any-cost mentality are a heady mix of money and fat hatred fueled, perhaps, by a thoroughly misplaced and misdirected urge to do good. (One "obesity" specialist at a noted university admitted during an interview with Sondra Solovay that his patients only have about a 3% chance of keeping any weight off. When asked why he would continue to subject them to prolonged starvation, given such odds, he said, "Maybe they’ll be one of the lucky ones.") We should expect better from our health care providers. The physician’s oath says, "First, do no harm."
I realize that the information in this chapter goes against everything you’ve been led to believe in our fat-hating culture. But I don’t think the conclusions this chapter offers are all that radical. I simply urge people of all sizes to eat right and exercise, and to stop worrying about weight. (Because worrying about your weight is, in itself, an unhealthy practice, and it can lead you to try things that are really bad for you.) Instead, hold on to a healthy skepticism. Hold on to your physical and mental health.
Feminist Reprise thanks Kya for her help in readying this article for the site.