The World Health Organization uses the term ‘globesity’ to describe a supposed epidemic threatening millions across the world with the specter of serious metabolic health disorders.
We cry foul: Those menaced “overweight” millions, it turns out, come disproportionately from disadvantaged populations, and no matter how fat or thin they are, it’s their marginalized status itself that harms health. “Fighting obesity” as a health target not only adds insult to the injury of poverty and stigmatization, it worsens the situation. Fat, while an expediently visible marker, is not the actual enemy. The move to banish it flouts scientific evidence while honoring half-hidden aesthetic and moralistic biases.
The incessant drumming about obesity mutes the fact that the root cause of the diabetes, heart disease, and other chronic afflictions disproportionately burdening the poor and socially disregarded may be the status quo. “Obesity-related” disease actually tracks your social status more than what size clothing you wear. In developed nations, data show, members of stigmatized groups, including those who are economically disadvantaged and people of color, are the most common victims of illnesses typically grouped under the “metabolic” umbrella. They are not only more commonly ill, but when they do get sick, can expect poorer prognoses than more socioeconomically advantaged people with similar conditions. And for all that, current medical interventions prove more effective for more advantaged patients, further widening the gap between healthy and sick, rich and poor, powerful and marginalized.
It is also true that members of marginalized groups are more likely to be fat, but it’s a false leap of logic to assume, based on that association, that fat causes metabolic disease. Too many other factors are lost when we simply conflate weight and health and close our minds to the other, more pernicious (less visually obvious) effects at work.
Before we can acknowledge the damage it does, it helps to understand that our collective concern about fat is strongly influenced by aesthetic and moral judgments. Try the Implicit Attitudes Test to see just how deeply this bias runs. These attitudes affect medical care, the reporting of science, and the type of research that gets funded, reinforcing a pseudo-scientific rationale centered on weight control as if were evidence based. As if we needed any more social stigmas, weight discrimination has been outpacing even race and gender discrimination. Deploring fatness, rather than leading to improved health for fat people, worsens health for all of us and increases inequalities.
All forms of discrimination rely on stereotypes that lead to unfair prejudice, and weight discrimination is no exception. Scapegoating fatness and fatter people leads to disadvantage throughout the life-course, from education through to the workplace, travel, adoption, healthcare, insurance – and research increasingly shows, this bias in itself promotes metabolic disease. Is it coincidence or just irony that these diseases happen to be the ones we usually blame on weight? Metabolic syndrome tracks inversely with social status: The lower you fall on the social scale, the more likely you are to develop symptoms. The phenomenon has often been blamed on poverty-induced “bad habits,” where poor nutrition and a lack of exercise are assumed to lead to weight gain. But even when we control for health behaviors and BMI, studies show the health discrepancies persist. (In a sampling of studies, health-related behaviors accounted for only 5 to 18 percent of neuroendocrine differences that lead to metabolic syndrome.) So what can be making disadvantaged and stigmatized people sicker, or more accurately, fatter and sicker, than the rest of us?
Poverty and lack of opportunity matter more to public health outcomes than weight, diet or exercise behaviors. For most disadvantaged people, if it’s Weight Watchers versus welfare, welfare wins, and no amount of extra gym time can outweigh time in the unemployment line. The day in day out strain of living in poverty and the experience of oppression and stigma lead to chronic physiological stress. We’re not talking long-line-at-Starbucks stress but the hyper-hormonal “fight or flight” chased-by-a-tiger rush that tenses your entire system for survival – at the expense of ordinary, necessary biological functions. Extensive research documents that chronic stress of this type can raise cholesterol, blood pressure, triglyceride levels, stimulate inflammation, and impair insulin sensitivity, all of which can lead to the metabolic conditions associated with obesity, including hypertension, diabetes, and coronary heart disease.
Do eating, exercise, and drinking patterns also affect these conditions? Sure, but contrary to mainstream spin, their impact is somewhere below 25 percent of measured causation, far below the impact of social status and daily psychological stress. With social status comes control over one’s circumstances – success at work, fostering loved ones’ well-being, being able to plan for the future, or even next week. The absence of those, no matter how punctilious our lifestyle habits, stresses our systems in disease-promoting ways. In contrast, being able to exert an influence over what matters to us is health-promoting.
Hectoring the population to “eat better, exercise and lose weight” misleads and has proven harmful, so it’s time for new approaches that cultivate equality and don’t harp on body size. Health – and social – policy must focus instead on equalizing life chances, reducing stigma and mitigating the physiological impact of stress. (Telling a patient she’s too fat, by the way? Not stress-reducing.)
Policies promoting weight loss as a solution – or even as possible in sustainable ways –perpetuate damaging stereotypes and a “healthist,” moralizing attitude. What’s needed are better, socially-integrated approaches to health. The most ethical, effective public health alternative to emerge to date is Health at Every Size, or HAES, which challenges fat bias and fosters self-care behaviors rooted in respect and nurture, not shame and denial. HAES practices have been shown in controlled trials to improve health habits, self-esteem and mental wellbeing as well as metabolic health. All without weight loss. And all without introducing weight bias. HAES practice abandons weight as an outcome in favor of markers of wellbeing. Treating oneself fairly and dispensing with fat shame, HAES studies show, lead to better self-care and – this should surprise no one who’s been told to lose weight – reduced stress. It helps people of all shapes and sizes learn to make peace with food and their bodies and, by supporting acceptance and preferring respect over bias, leads us closer to the fair societies that form the cornerstone of healthy communities.
Written in honor of Weight Stigma Awareness Week, September 23 – 27, 2013, co-sponsored by the Binge Eating Disorder Association, imagining a world where people are supported in living happy, healthy lives, free of judgment about the size of their bodies.