On Fat-phobia Masquerading as Public Health

There are many reasons that I believe our collective discussion about the "obesity crisis" reveals more about our irrational aesthetic biases than about our passion for public health outcomes.

First, much of the accepted public wisdom that being fat is deadly stems from non-experimental, correlational science. Simply put, these large N studies simply correlated whether fatter people tended to die earlier or develop chronic conditions. They would have been unable to exclude the possibility that an unidentified confounding variable was correlated with both fatness and the outcome in question, unless they explicitly controlled for it. It turns out that these studies often failed to control for diet composition and exercise levels, both of which could be just such confounding variables. In other words, perhaps it's lack of exercise and poor diet that lead to poor health outcomes, not fatness per se. Perhaps a fat person who eats a healthy diet and exercises regularly will be indistinguishable in their health outcomes from the general population.

My reading of the thrust of the research is that this is exactly what those early studies failed to do, making fatness seem much more harmful than it actually was. Now that there are studies that correct for activity levels and diet, excess adipose tissue is clearly still a risk factor for developing health problems, but the correlation is much lower.

All fat is not created equal. Fat around the abdomen appears to be more risky than fat around the hips and thighs and butt (unfortunately, that's where mine is).

I was recently diagnosed with type 2 diabetes. I'm fat. There's good evidence that visceral fat (fat round the gut) is hard on one's organs and probably contributed to my insulin resistance and pancreatic dysfunction, but there's also clearly a genetic component, as I have diabetes on both sides of my lineage. There are plenty of people as fat and inactive as me who aren't diabetic. How much of my condition is about my fatness per se, and how much is it about my diet, or my activity level, or my genetics? It's impossible to say. Excess visceral fat is not ideal. It carries health risks. That's definitely true.

But society's obsession with the "obesity crisis" is not proportionate to the level of health risk that fatness poses. There are many risky behaviors that do not bear the social stigma of being fat but that present similar levels of risk. Stress and lack of sleep, for instance, are extremely bad for one's health, but we don't have television shows called "The Biggest Sleeper!" or about CEO's learning to meditate. Riding motorcycles, mountain climbing, gun sports, jet skis, boating...these are all risky behaviors that can cause serious injury or death. Do we have a whole section of the book store dedicated to convincing people not to ride motorcycles? No. But we have libraries full of books telling people how to lose weight. Do people see wilderness trips as an irresponsible, self-indulgent behavior that should be condemned? No. We celebrate those people for their bravery, even when we have to spend huge sums in taxpayer dollars to rescue lost hikers every year.

Society's concern-trolling about fatness is xenophobia and aesthetics cloaking itself with the altruistic cover of public health. It's not that being fat carries no health risks; it's that the time and energy we spend obsessing over it does not correspond to its actual level of risk. Cloaked with the holy vestments of public health, people feel free to let their natural aesthetic revulsion at fat people's appearance run amok. It's confirmation bias: see, I knew my aesthetic reaction to fatness wasn't just my shallow, petty belittling of those who are different. No, it's actually justified, because I'm really a warrior for good public health. Anything that allows people to feel self-righteous about their natural prejudices will be gobbled up like candy (so to speak).

If we truly cared about public health, we would encourage healthy eating and regular exercise, because these really ARE that beneficial, and the lack thereof really ARE that harmful. But we would relegate body size per se to a much less histrionic place in our public discussions, on par with other comparable risks that do not command nearly the level of public attention or visceral reaction that fatness does. We would not see body size as indicative of character flaws, self-indulgence, weak will, or intelligence. Fat people would not face the level of employment discrimination they deal with today. Fatness would instead be an issue for people to discuss individually with their doctor and would generally not be anybody else's concern.

In short, a person's body size is a poor proxy for the level of health. There are very healthy fat people, and unhealthy thin people, because body size and healthy living have a low correlation. One can run a positive calorie balance (the cause of fatness), while eating a healthy diet and exercising regularly. The benefits of those behaviors are myriad. And, one can run a neutral or negative calorie balance, be thin, and still eat like crap and never exercise.

If society wants to concern-troll about public health, let it be about those behaviors that ACTUALLY contribute to health (eating well; exercising; safe sex; avoiding drinking, drugs, and smoking; avoiding risky behaviors; sleeping enough; stress reduction) and relegate fatness to the relatively minor place that it deserves.