Can you be overweight and still be fit?

Excess weight carries health risks. But how much is too much?

Published: July, 2018


Image: © FredFroese/Getty Images

The idea that someone can be “fat and fit” — that is, overweight but still healthy — has been around for some time. But don’t be fooled.

“The latest science is quite clear that excess weight can carry considerable health risks, including a higher risk for heart attack and stroke,” says Dr. Jorge Plutzky, director of preventive cardiology at Harvard-affiliated Brigham and Women’s Hospital. “While there is no one-size-fits-all number when it comes to a person’s ideal weight, men should not ignore significant weight gain and the implications it has for their future health.”

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Is There Such a Thing as ‘Healthy Obesity’?

Can a person be both obese and healthy?

That question is at the center of a new paper published in the Annals of Human Biology this month.

In the paper, Dr. William Johnson of the School of Sport, Exercise and Health Sciences, at Loughborough University in the United Kingdom, brought up the idea that the term “healthy obesity” should be retired.

Johnson writes, “It is undeniable that obesity is bad for health, but there are clearly differences between individuals in the extent to which it is bad.”

Johnson favors a more nuanced look at body mass index, or BMI, since there are numerous other contributing factors that determine a person’s health. These include whether they smoke and their likelihood of developing certain conditions later in life.

Currently, a BMI over 30 is considered obese.

Johnson explains that the term “healthy obesity” is flawed since people who are obese, even those who are “metabolically” healthy, are still at increased risk for a host of health conditions, including type 2 diabetes, chronic kidney disease, and overall increased risk of mortality.

“While the concept of healthy obesity is crude and problematic and may best be laid to rest, there is great opportunity for human biological investigation of the levels, causes, and consequences of heterogeneity in health among people with the same BMI,” Johnson said, pointing out people with the same BMI can have different health risks.

What is healthy?

The notion of whether “healthy obesity” is a flawed term remains controversial.

Sharon Zarabi, RD, the bariatric program director at Lenox Hill Hospital in New York, said it’s unhelpful to say a person who is obese can’t be healthy.

“I think we need to move away from using BMI as categorizing one as obese/overweight or unhealthy,” Zarabi told Healthline. “The real debate here is how do we define health? Is the vegetarian who has a BMI of 30, avoiding all saturated fats from meats and consuming a diet heavy in simple carbohydrates reducing his risk of cardiac disease but increasing likelihood of elevated triglycerides and insulin, considered healthy?

“I think we need to redefine health and look at the overall person as a whole, taking into account fitness level, sleep patterns, joint pain, vitamin levels, breathing, strength, happiness, social connections,” she added.

She pointed out other tests can look at health more holistically, such as the “sit test” to determine if patients can get up out of a chair easily.

Rebecca Scritchfield, a registered dietician nutritionist and author of “Body Kindness,” said she was disappointed the paper made no mention of the stigma obese patients already face in the medical setting.

She pointed out there are few if any cases of obese people being told they’re healthy while overweight.

“The dominant impression is that if you are the higher weight, you are unhealthy,” Scritchfield told Healthline.

Scritchfield said that Johnson’s arguments presented his opinion as fact.

“ it’s undeniable that obesity is bad for health, but that is an opinion,” Scritchfield said. “That is not necessary true because there’s just as much research out about how weight bias is harmful to health and may even shorten life expectancy.”

Obese people “tend to avoid their medical doctor because they… don’t want to get a lecture about their weight,” she said.

Scritchfield pointed out that while these people may be at risk for health complications such as type 2 diabetes, their weight doesn’t ensure that they will get those complications.

“You could have people do the same thing and they’re going to be a different weight, including weights that would be in the obesity category,” she said. “It’s not unthinkable that the term would exist.”

Getting proper treatment

Scritchfield said that debating the term “healthy obesity” isn’t likely to help people trying to stay healthy.

Instead, doctors should focus on making patients feel comfortable so they get treatment.

“I would say more doctors should be looking at the ways that they contribute to weight stigma without necessarily knowing it,” she said. “If you really care about improving the health and well-being for people, including the higher weight people, the best thing they can do is reduce the stigma.”

Scritchfield said there are ways physicians can interact with obese patients without making them feel shame so as to increase the likelihood that they will return for care.

She said physicians should ask a patient if they want to discuss their weight or diet and not assume that patient doesn’t exercise or take steps to eat healthy.

Scritchfield said that doctors should treat their obese patients as they would their patients who aren’t obese, and not focus all of their attention on weight or diet.

“Health is individual, and it depends on a number of factors for physical and emotional health; it is not weight dependent,” she said.

Janis Christie/Getty Images

The idea that people can be overweight and yet still quite healthy began gaining scientific and popular credence some years ago, fueled by the publication of a number of studies showing that men and women who were a few pounds overweight but physically active had less risk of developing cardiac disease than people who were of normal weight but sedentary.

Some scientists and doctors began speculating that healthy people who were sporting extra pounds didn’t necessarily need to worry about losing weight. As one researcher told a reporter in 2004, “If a fat person or obese person has normal blood pressure, if their total cholesterol and glucose levels are normal and they are healthy, there is no reason they should necessarily have to lose weight.”

But several new studies are raising questions about that comforting notion at a very inopportune moment, with the holiday overindulgence season barely behind us. In the most recent of these studies, published online on Dec. 28 in the journal Circulation, Swedish researchers examined medical records reaching back 30 years for a group of more than 1,700 middle-aged men in the city of Uppsala.

The men were measured and tested when they reached the age of 50 and then periodically for the next 30 years. They were categorized into groups based on their body-mass indexes and metabolic profiles, a good marker of overall physical health and fitness. Some were normal weight; some overweight (meaning they had a body-mass index of 25 or above); some obese (a B.M.I. greater than 30). In each of these groups, some had normal metabolic profiles, while others were afflicted with a variety of conditions known collectively as metabolic syndrome. A diagnosis of metabolic syndrome means that you suffer from three or more of these conditions: impaired ability to handle blood sugar, high blood pressure, elevated blood fats, low HDL (“good” cholesterol) and a large waist circumference.

To no one’s surprise, the Swedish researchers found that being overweight or obese and having metabolic syndrome was quite unhealthy. Overweight men in that group had a 74 percent higher risk of developing cardiovascular disease by the time they turned 80. Obese men with metabolic syndrome had a 155 percent higher risk. Even being of normal weight, if you had metabolic syndrome, was dangerous. Men in this group, with normal girths but poor cholesterol and blood-pressure readings, had a 63 percent higher risk of developing heart disease than normal-weight men without metabolic problems. In other words, you don’t want to have metabolic syndrome, even if you’re thin.

More startling, though, was the study’s finding that being overweight with no evidence of metabolic syndrome left you at significantly higher risk for heart disease than if, with the same metabolic readings, you were not overweight. Men who were overweight (not obese) with healthy blood pressures, cholesterol readings, blood glucose levels and so on, still had a 52 percent higher risk of developing heart disease within 30 years than men who were normal weight and had similar metabolic profiles. That risk rose to 95 percent among obese men who didn’t suffer from metabolic syndrome.

The researchers did not report on the activity levels or exercise practices of any of the men, but typically more-active people have healthier metabolic profiles and vice versa. The findings did make it clear that although being fat and having healthy blood work puts you at less risk of cardiac disease than someone who is thin and has lousy metabolic parameters, the extra pounds still leave you with at least a 50 percent greater risk of developing heart disease.

“Previous studies have put forward the existence of a ‘metabolically healthy’ subgroup” of overweight people “who are at no increased cardiovascular risk,” Johan Arnlov, Ph.D., an associate professor at Uppsala University and the study’s lead author, said in a statement. But “if you follow them long enough, you find out there appears to be no such thing as metabolically healthy” extra poundage. (To assess your B.M.I., plug your height and weight into this calculator from the National Heart, Lung and Blood Institute.)

Another recent large study found somewhat similar results among women, although it looked at activity levels, not metabolic profiles, to assess health and fitness. That report, published in 2008, used data on almost 40,000 women enrolled in the Women’s Health Study. Its authors found that women with a higher B.M.I., even if they were active, had an elevated risk of coronary heart disease compared with women engaging in an equal amount of activity who were of normal weight. Being fit, for the thousands of women under consideration here, lessened but did not fully mitigate the health problems associated with being fat.

Then there are football players, a group — particularly the linemen — who would seem to be advertisements for hefty-size health and fitness. But according to a study presented in October at the Annual Scientific Meeting of the American College of Gastroenterology, when scientists studied current N.F.L. linemen, they found that those athletes had a significantly greater incidence of metabolic syndrome than a group of less-bulky professional baseball players.

Why body size and composition should affect someone’s risk for heart disease and metabolic problems even if their body is otherwise apparently healthy remains a contentious issue. Some researchers, including the authors of the Women’s Health Study-based report, say that fat is itself a tissue with unhealthy properties. Fat can release inflammatory molecules, which increase the risk of diabetes and heart disease. Fat may also interfere with muscle function, as an article published this week in the Journal of Physiology points out, referring to several newly published studies.

“The fit or fat issue has unbelievable levels of complexity,” says Tim Church, M.D., Ph.D., the director of Preventive Medicine Research at the Pennington Biomedical Research Center in Baton Rouge, La. Perhaps being active affects how fat cells operate in a heavy person. Age plays a role, too, he says, as do genetics. The very categorization of fatness using B.M.I. is a gross oversimplification, he adds. “You can’t just say being overweight” is unhealthy, he says. “Nothing is that simple.”

So what can we take away from the most recent studies? If other scientists replicate the findings of the Swedish and Women’s Health Study-based reports, the message is clear if disconcerting: being overweight, even if you have sterling blood-cholesterol levels or a firm commitment to exercise, does increase your risk of heart disease, and you should probably try to lose the extra pounds.

“Some researchers have suggested that a heavy person without other risk factors didn’t need to lose weight,” said Johan Arnlov, M.D., Ph.D., the lead Swedish researcher, in a statement. ‘Our data does not support this notion.”

It pains me, but I’ll be tossing out my last Christmas cookies now.

Q: I’m a bit overweight, but I exercise a lot. I’m frustrated. Is it possible to be fat and fit?

A: Yes, you can be overweight and in good shape at the same time. In fact, physiologists now believe that being overweight and fit is far healthier than being skinny and out of shape.

How much healthier? One recent study of 2,600 people shows that subjects who were unfit were four times more likely to die than those who were very fit — whether those fit people were normal weight, overweight, or obese. That’s because exercise — no matter how much you weigh — reduces your risk of a broad range of ailments, including cardiovascular disease, cancer, and diabetes.

If you’re very out of shape or if you have heart disease, high blood pressure, or diabetes, talk to your doctor before starting an exercise program. But remember that even starting out slowly confers some benefits.

According to exercise physiologist Stephen Blair, who has conducted several studies of fitness and mortality, taking just three 10-minute walks a day, five days a week, will keep you healthier.

Get more exercise and you’ll reap even more benefits, including shedding some of that extra weight.

Laurie Anderson, RN, FNP, MSN, WebMD Heart Disease Expert

For those who are overweight or obese, it may be frustrating to increase your activity—say, you take up running—and still not see any movement downward on the scale. You know you should keep at it, but it can be difficult to stay motivated when you’re not seeing any outward results.

But this might help you continue lacing up your running shoes: Being fit can seriously help your health, even if you are still carrying some extra weight, a new preliminary study presented at the American Heart Association’s annual conference suggests.

In the study, researchers from the University of Texas Southwestern Medical Center analyzed data from over 2,300 patients enrolled in the Dallas Heart Study. They split them into four groups based off their body mass index (BMI) and their fitness, which they gauged by performance on a treadmill test: non-obese and fit, non-obese and unfit, obese and fit, and obese and unfit.

The researchers discovered that obese people who are fit had less body fat, more lean muscle mass, and a lower resting pulse rate—a marker of efficient heart function—than non-exercisers who are also obese.

Particularly notable, these exercisers have better cardiovascular health, which can cause a cascade of beneficial effects, including longer life. That shows there may be some truth to being “fat but fit”: “Being fit is linked to beneficial physiological and cardiovascular changes, irrespective of BMI,” the researchers write.

The increase in lean muscle mass is an important key, said Salim Virani, M.D., a professor in cardiovascular research at Baylor College of Medicine who wasn’t involved in the study. That shift can boost metabolism, helping regulate your blood sugar spikes more effectively. As a result, that can decrease your risk of diabetes as well as heart conditions.

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Bottom line? The takeaway from this research is that even if you are overweight or obese, you can still lower your risk of heart or stroke through physical activity—even if you don’t lose any weight, Virani said.

He emphasized that people who are overweight shouldn’t put off the start of a regular exercise regimen until they drop a few pounds through dietary changes.

“Most patients, even if obese, can generally get into some regular exercise routine,” he says. “Of course, one should gradually build this into the schedule. The key is gradual increase in duration and intensity. The important message is to get started with whatever activity one can tolerate.”

Knowing that exercise improves health markers may be an incentive for those who are overweight and feeling frustrated about lack of “progress” when it comes to weight loss, he adds.

“There are many health benefits of regular physical activity and exercise which go beyond weight loss,” says Virani. “Any amount of physical activity is better than no physical activity.”

Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: Melissa Conrad Stöppler, MD

The results of a study published in the Archives of Internal Medicine should not come as a shock to most people. Being overweight doesn’t necessarily make you unhealthy, according to researchers in both the United States and Germany. Sports fans have known this forever; elite athletes can have an appearance ranging from tiny Olympic gymnasts to massive NFL linemen. Athletes at both extremes- and all those in between- are in shape and trained to perform at high levels.

The new research confirmed this. People who are overweight have a fifty-fifty chance of having high cholesterol, high blood pressure, or elevated blood sugar levels. Pretty good odds, but not as good as those for people who are within the normal weight range. They have a 75% chance of having normal results on blood tests for cholesterol and blood sugar. And for those who are obese, the chance of having normal results falls to one-third.

The definition of “ideal body weight” has been a thorn in the side of many people. Perceptions of how people appear, how their clothes fit, and how fat they are have permitted whole industries to flourish. Weight loss clinics, gyms and fitness centers, liposuction, and gastric bypass surgeries all were based at least partly on the presumption that being overweight equaled being at risk for heart disease and diabetes. The studies in the Archives of Internal Medicine found that there may be more to health than meets the eye.

There aren’t many risk factors for heart disease and stroke, the big killers in the United States. Smoking, high blood pressure, high cholesterol, diabetes, and family history are the factors that decide who will develop atherosclerosis (narrowing of the arteries). Aside from family history, the rest of these factors can be controlled and therefore, risk minimized.

The key to risk management is not what you look like, but what the numbers say; that may require a person to take preventive action. You can’t look in the mirror and see high blood pressure or high cholesterol; you need to take positive action and visit a health care provider.

The study reminds us that looking after the body is no different than car maintenance. You can look at the exterior of a car or truck and decide whether you like the shape and style, but its external appearance gives you little information on how the engine is holding up. Routine maintenance with an oil, lube, and filter, checking the fluid level, and changing the belts will the let the car run almost forever. The same principles apply to the body. Routine maintenance allows the body to function well and hopefully run forever.

Deciding about what constitutes an ideal weight using a scale or measuring body mass index (BMI) can be deceiving. Professional basketball players tend to have elevated BMI scores, but they carry significant muscle and little fat on their frames. Football players tend to be big, but their physical activity and training decreases their heart and stroke risk factors.

The bottom line remains the same. What we look like on the outside doesn’t really matter; it’s what’s inside that really counts.

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On Thursday, Joe Biden, the Democratic frontrunner for president, angrily confronted a voter in Iowa who didn’t like him very much. Biden deemed him a “damn liar” and “too old to vote for me” and maybe, just maybe, “fat”.

The man, an 83-year-old retired farmer, had challenged Biden on one of his many vulnerabilities – his son’s high-paying work for a Ukrainian energy company. Without direct evidence, the man said Biden, then the vice-president, secured his son the job. “You’re selling access to the president just like is,” the unidentified man said.

The man also attacked the 77-year-old’s fitness for the presidency, saying Biden was “too old for the job”.

“I’m not sedentary,” Biden fumed in response. “You want to check my shape on, let’s do push-ups together, let’s run, let’s do whatever you want to do, let’s take an IQ test.” He also apparently added, during the exchange, “But look, fat, here’s the deal,” though his campaign maintains that Biden had begun to say “look, facts”.

The confrontation was vintage Biden: rambling if aggressive, swaggering and strange. A thousand takes flew. Voters and pundits wondered if the gaffe-prone Biden was up for challenging President Donald Trump, the clown king of trolling.

It may be difficult to remember, but Biden was once praised for his aggressive style, in particular the perception that he brawled effectively with Republican Paul Ryan during the 2012 vice-presidential debates. Though deeply flawed as a candidate, Biden should not be underestimated in the Democratic primary and, if he prevails, in a match-up against Trump. Voter turnout will probably surge and anyone, Biden included, running under the Democratic banner will benefit from a furious and united anti-Trump vote. Biden’s punch-drunk routine could go over well against an infantile bully like Trump. We know that, at the very least, Biden won’t shrink from a fight.

But the confrontation with the Iowa voter, a self-professed Elizabeth Warren supporter, underscored that Biden is not the ideal Democrat to put up against Trump. A disciplined, unflappable messenger – Bernie Sanders comes to mind – could better prosecute the case without taking the schoolyard bait of responding to a dopey nickname.

More importantly, the Iowan highlighted a more telling weakness: Biden’s disastrous foreign policy record. Hunter Biden was earning as much as $50,000 a month while sitting on the board of one of the largest natural gas companies in Ukraine during his father’s vice-presidency. While it’s not illegal to make a living abroad, there is little question that, were Hunter’s last name not Biden, he wouldn’t have been able to secure such a lucrative gig. Neither vice-president nor son seemed to care about the appearance of impropriety.

It’s also not clear Biden knows how to effectively attack Trump. Though Biden’s latest broadside against the president – a video of world leaders mocking him, which was enthusiastically praised by the liberal political class – may have seemed like a grievous blow, it was an inadvertent reminder of why Trump won in the first place. Demonizing global elites was always Trump’s calling card; a farmer in Iowa or a laid-off factory worker in Michigan doesn’t necessarily care if the French laugh at us.

Trump won a Republican primary in part by ridiculing a rival, Jeb Bush, for being related to the president who started the Iraq war. Biden enthusiastically supported that foreign intervention, the most catastrophic since Vietnam, and has rarely met a regime-change conflict he didn’t like. He has no serious proposals for ending the wars in Yemen or Afghanistan. He has been an unstinting supporter of Israel’s rightwing governments. His hope is to restore some sort of vague, cold war-era consensus, with Russia as the eternal enemy and American troops marching across the world.

Due to a cocktail of lingering political talent and sexism, Biden may avoid being stamped as an out-of-touch globalist like Hillary Clinton, though their approach to governing is indistinguishable. Politics in this country can be as much aesthetics as anything else. A bumbling brawler just doesn’t seem like a booster of cataclysmic war.

So Biden in Iowa, perhaps calling a man fat, may be on to something. The longer we think of him this way, as a grandpa longing for push-up contests and tripping over his words, the less we remember what he truly is and what he did.

  • Ross Barkan is a writer and journalist in New York City

Body positivity began as a powerful antidote to the media’s obsession with skeletal models and beachball-breasted glamour girls. Empowering women of non-Barbie proportions to feel good about themselves, the movement has attacked impossible beauty ideals that confront us in advertising, branding and beyond, criticising everything from the thigh gap trend to green juice cleanses.

Its success has led to a series of positive changes, including the decision to ban the use of rail-thin models in several European countries. In the UK, body positivity has fuelled a backlash against the clean eating movement, with health experts linking questionable nutritional advice to a rise in eating disorders such as orthorexia. As glossy-haired treadmill unicorns continue to pout their way through Instagram with chia-seed recipes and colonoscopy recommendations, women are rejecting their raw food cleanses in favour of a balanced diet that includes the occasional doughnut.

But as we move away from the skinny goals of the mid-2000s and embrace different shapes and sizes, one group of campaigners has taken things a step too far. Fronted by plus-sized models and social media influencers, the fat acceptance movement aims to normalise obesity, letting everyone know that it’s fine to be fat. With terms such as “straight size” and “fat pride” proliferating, some influential figures are now even likening the valid concerns of health officials to hate crimes.

The comedian Sofie Hagen has accused Cancer Research of bullying fat people. Photograph: Karla Gowlett

The comedian Sofie Hagen recently accused Cancer Research of bullying fat people, after the charity launched a campaign to raise awareness about the link between cancer and obesity. Through a series of expletive-laden tweets, she criticised the organisation for its damaging messages, claiming that fat didn’t equal unhealthy.

While nobody should ever be bullied for their weight or food choices, it’s important to make a distinction between health awareness and cruelty. Cancer Research wasn’t criticising a specific person for being overweight, they were pointing out that obesity is now the second leading cause of lifestyle-related cancers, a fact only 15% of the British public are aware of.

Medications, mental health, social deprivation, self-esteem and genetics all play a role in our ability to control our weight, and judgment is never a constructive approach. But suggesting that being a size 30 is just as healthy as being a size 12 isn’t a body-positive message either – it’s an irresponsible form of denial.

According to the NHS, we’re in the grip of an obesity epidemic, which has led to increased pressure on the struggling health service. The latest figures reveal that weight-related hospital admissions have risen by 18% in the past year, with more than a quarter (26%) of British adults now classified as obese. Another recent study, which measured the metabolic health of more than 17,000 respondents, showed that overweight people who exercise regularly and consider themselves “fat but fit” still had a 28% increased risk of heart disease, compared to their slimmer counterparts. As well as being linked to diabetes, obesity can also be responsible for osteoarthritis, gout, breathing problems, high blood pressure and other conditions. While being thin won’t automatically grant you a clean bill of health or a long, smug life of squeaky clean arteries, there’s no denying that health risks are higher for obese people.

Public health campaigns are not designed to flatter people’s egos, but to raise awareness about potential health dangers. Since the ban on indoor smoking in 2007, tobacco enthusiasts have been turfed out through a side door to puff on their cancer sticks in the rain. Smoking is an addiction that many struggle to control, but we don’t celebrate it with viral social media campaigns about smoking pride. Although we acknowledge that some smokers can run 10 miles or live into their 90s, we recognise that the overall risks of tobacco inhalation are high, and vastly increase the odds of a premature death. So what makes obesity different?

Whether we want to gorge on 3kg of chocolate, drink until we vomit in the bathtub or line our lungs with carcinogenic tar, informed adults are free to make their own choices. But while your own body is your business, actively encouraging unhealthy lifestyle choices and denying health risks in a public space isn’t promoting body positivity – it’s just giving the green light to different kinds of eating disorders.

• Lizzie Cernik is a journalist and features writer, covering relationships, travel and women’s issues

“Obesity is the biggest threat to the health of our nation,” proclaims the chief of epidemiology at a major medical school on the Scientific American Observations blog. This all too common suggestion does far greater damage to public health than fat tissue itself. When the focus is on weight and body size, it’s not “obesity” that damages people. It’s fearmongering about their bodies that puts them at risk for diabetes, heart disease, discrimination, bullying, eating disorders, sedentariness, lifelong discomfort in their bodies, and even early death.

Anti-obesity campaigns are so common and normalized these days that some readers might consider our claim as the outrageous one. Yet, consider this: stigmatizing and imposing shame on bodies, whether individually or as a group of people, is hurtful both to the vilified fat people and to the thinner people who are taught size prejudice and instilled with a fear of becoming fat. (“Fat” is used here as a descriptive term stripped of pejorative connotations, reclaimed by a growing fat acceptance movement.)

When the culture and the medical world are constantly pushing the idea that “obesity” needs to be eliminated, it’s not the fat cells that are feeling that stigma—it’s the fat people. This hierarchy of bodies is nothing new, with roots in racism, slavery and every other attempt to rank bodies. We can no longer pretend that being less likely to be hired or get promotions, being paid less, receiving biased medical treatment, being socially excluded and bullied are attempts to help people “be healthier.” These are the direct consequences of living in a culture that vilifies and fears fat bodies and that treats the people living in them as morally lesser beings.

From my (Linda) decades of challenging the pervasive “fat is bad” rhetoric, I know that every time I assert that the problem for fat people isn’t their bodies, but abuse from society, bigotry fights back. It’s not just the outright haters who populate the comments section, but worse, the self-righteous who see their stance as caring. It’s all about health, their argument goes, not bias.

No, it’s not. Intent does not negate impact. You cannot wage war on obesity without waging war on the people who live in those “obese” bodies. Moreover, the dignity of a group should not be contingent on whether its members are deemed healthy, eating “right,” or exercising regularly. It should be obvious, but weight stigma does not reduce “obesity”—and health care should be about self-care and promoting the health of the person in all its forms.

“Obesity”—the word itself is a problem, pathologizing the size of a body. It is a category based on the body mass index (BMI), which is simply a mathematical equation based on height and weight. It measures physical appearance, not health. It was never intended to be used for individual health concerns, but rather for statistical analysis of a group. When the American Medical Association declared obesity a disease, it overrode a recommendation by its own expert panel, which stated that correlations between “obesity” and morbidity and mortality rates did not establish causality and there was concern that medicalizing “obesity” would lead to further stigmatization and unnecessary treatment.

Even a quick glance at the weight research shows that, despite decades of trying, there is no evidence that efforts to prevent or reverse “obesity” are successful. In fact, there’s much evidence to suggest that the prescription for weight loss is more likely to result in physical harm and weight gain. The data also refute other longstanding, widespread—and incorrect—notions about health and weight. Like the “fact” that fat is a primary driver in metabolic disease. Or that weight loss prolongs life or improves health. None of this is true. Dogma, myths, and prejudices about fatness have trumped actual evidence in our view of weight and health.

It is true that many diseases are more commonly found in heavier people. However, that doesn’t mean that weight itself causes disease. Blaming fatness for heart disease is similar to blaming yellow teeth for lung cancer, rather than considering that smoking might play a role in both. And telling people they need to lose weight is a lot like telling someone with a cold to stop sneezing so much—it may not be possible and won’t make the cold go away.

Focusing on weight—or health behaviors—puts the burden on the individual, deflecting attention from the more pernicious problem: systemic injustice. Conditions in the places where people live, work, and play affect health outcomes to a much larger degree than health behaviors, which, all told (including eating, activity and other behaviors), account for less than 25 percent of differences in health outcomes. While health behavior change is valuable, to truly improve public health, we can work harder to create an inclusive society where everyone feels valued and has the opportunity to create a good life for themselves. Combating fat-phobia needs to be part of that agenda.

Ethical and effective public health intervention challenges fat bias and fosters self-care behaviors rooted in respect and nurture, not shame. I’ve seen it in my (Linda) research examining the Health at Every Size®1 (HAES) paradigm, as have many others. HAES practices have been shown in controlled trials to improve health habits, self-esteem and psychological well-being as well as metabolic health—all without weight loss or introducing weight bias. The HAES movement takes the focus off of weight change and supports people of all sizes in finding compassionate ways to take care of themselves, helping to advance social justice as it improves health outcomes.

For the HAES naysayers and those fighting to end obesity, we urge you to examine why these beliefs are so deeply held and what about challenging them is challenging you.

For those who feel the stigma of a fat body or fear of a fat body, we want you to know this isn’t your personal failing, it’s our culture that is failing you. It’s not easy to appreciate your body in a culture where your body is vilified. Oppression, by removing us from belonging, is writ large upon our bodies and literally killing us.

But places of refuge do exist and healing is possible. We urge you to look for an accepting and appreciative community. We are heartened to know the possibilities grow stronger by the day. Finding ways to belong to each other and create refuge for each other can help shift the world around us—until one day, all bodies are valued and all of us feel a sense of belonging.

The authors thank members of the ShowMeTheData listserv for critical review.

1Health at Every Size and HAES are registered trademarks of the Association for Size Diversity and Health and used with permission.

60%of the calories Americans consume come from “ultra-processed foods”Source: British Medical Journal, 2016

And so, working within a system that neither trains nor encourages them to meaningfully engage with their higher-weight patients, doctors fall back on recommending fad diets and delivering bland motivational platitudes. Ron Kirk, an electrician in Boston, says that for years, his doctor’s first resort was to put him on some diet he couldn’t maintain for more than a few weeks. “They told me lettuce was a ‘free’ food,” he says—and he’d find himself carving up a head of romaine for dinner.

In a study that recorded 461 interactions with doctors, only 13 percent of patients got any specific plan for diet or exercise and only 5 percent got help arranging a follow-up visit. “It can be stressful when start asking a lot of specific questions” about diet and weight loss, one doctor told researchers in 2012. “I don’t feel like I have the time to sit there and give them private counseling on basics. I say, ‘Here’s some websites, look at this.’” A 2016 survey found that nearly twice as many higher-weight Americans have tried meal-replacement diets—the kind most likely to fail—than have ever received counseling from a dietician.

“It borders on medical malpractice,” says Andrew (not his real name), a consultant and musician who has been large his whole life. A few years ago, on a routine visit, Andrew’s doctor weighed him, announced that he was “dangerously overweight” and told him to diet and exercise, offering no further specifics. Should he go on a low-fat diet? Low-carb? Become a vegetarian? Should he do Crossfit? Yoga? Should he buy a fucking ThighMaster?

“She didn’t even ask me what I was already doing for exercise,” he says. “At the time, I was training for serious winter mountaineering trips, hiking every weekend and going to the gym four times a week. Instead of a conversation, I got a sound bite. It felt like shaming me was the entire purpose.”

All of this makes higher-weight patients more likely to avoid doctors. Three separate studies have found that fat women are more likely to die from breast and cervical cancers than non-fat women, a result partially attributed to their reluctance to see doctors and get screenings. Erin Harrop, a researcher at the University of Washington, studies higher-weight women with anorexia, who, contrary to the size-zero stereotype of most media depictions, are twice as likely to report vomiting, using laxatives and abusing diet pills. Thin women, Harrop discovered, take around three years to get into treatment, while her participants spent an average of 13 and a half years waiting for their disorders to be addressed.

“A lot of my job is helping people heal from the trauma of interacting with the medical system,” says Ginette Lenham, a counselor who specializes in obesity. The rest of it, she says, is helping them heal from the trauma of interacting with everyone else.

Is being fat healthy?

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