CW: talk about body weight, obesity, weight stigmatization.
While I was busy grading last December, a report came out in the New England Journal of Medicine that predicted an almost 50% obesity rate in the US by 2030. The report also predicted that almost 25% of Americans would, by that time, be “severely obese” (a term I’m not going to use again, but which means a BMI of at least 35).
This is certainly not good news. However, some people are more worried than others. Jane Brody of the New York Times calls it “dire” and compares it to global warming:
Climate change is not the only source of dire projections for the coming decade. Perhaps just as terrifying from both a health and an economic perspective is a predicted continued rise in obesity, including severe obesity, among American adults.
Brody interviews experts who point to increased snacking, consumption of sugar-sweetened beverages, eating out more, and increased portion sizes as contributing culprits of the trend.
They make the usual policy recommendations, including taxes on sweetened sodas and other sugary beverages (which, in this recent study, found a reduction in sales after being implemented, but may mean that people purchased them in other places); working to create policies to promote reduced meat consumption, reduced portion sizes, and lower-calorie foods. These are the standard responses, and I think old news.
Reading through the original article, though, a number of things struck me that Jane Brody didn’t mention at all. I’ll share them with you, and I’d love to hear what you think as well.
First takeaway: the projected distribution of increased average BMI is not uniform throughout the US. We see it graphically displayed below, with darker colors indicating higher percentages of BMI30+, and BM 35+, respectively.
And what do we see? As an American, I see poorer states, states whose citizens get less good healthcare, states whose legislatures refused to expand Medicaid under the Affordable Care Act. The US is a country with severe health care inequality, and that shows in these graphs and in the tables in the article.
Second takeaway: the NEJM article talks about increase in “severe obesity” (I promised I wouldn’t use it again, but this is really the last time) but that term just means BMI 35+. We know that not all BMIs 35+ carry the same medical risk profiles. The authors of the article mention the need for more information across the BMI spectrum, but their analysis represents a shift only from BMI 30+ to adding BMI 35+. It’s also important to know the distribution BMIs 35–40, 40–45, 45–50, and so on. Why? Because they represent different health needs, and mandate different approaches to health promotion. I’m talking not only with respect to medical conditions that often go along with say, BMIs 50–55, but also with respect to responses that help citizens of those sizes navigate life, work, medical, educational and other public spaces. Which gets me to my next point.
Third takeaway: if we expect many of our citizens to be much larger in the next 10 years and we want them to be healthier, we need for them to be able to be active and present in the community, not barred from participating in ordinary activities of life. Yes, I’m talking about literally making space for larger and heavier populations (from restaurant chairs to hospital gowns), but not just that. We need a variety of ways to make physical activity accessible, easier, and safer for larger people. This means exercise machines that obviously handle larger weights, wider yoga mats, bikes with higher max weights. This also means more outdoor spaces tailored to physically accessible and satisfying activities (e.g. shorter nature trails with benches, railings, surfaces with less steep grades, etc.).
Last takeaway: the NEJM article acknowledges that medical research hasn’t been successful in developing weight-loss methods that will be able to reverse this trend on a nationwide level. The authors suggest turning to prevention as the most important strategy for health. I disagree. I think the most pressing agenda item is reducing weight stigmatization, especially in health care. Health care workers are the second-most common source of weight stigmatization, and the effects on people are a real hazard to their health. We know that stigmatizing weight doesn’t motivate people to lose weight, but instead reduces self-esteem, increases depression and anxiety and social isolation, and often results in increased body weights among those stigmatized. The Lancet published a series in 2015 (I wrote about it here in the Conversation) in which they made a number of recommendations for reframing obesity. One of them was to treat obese patients better. Yes, that sounds right. Let’s do that.
What do you think about these takeaways? Do you have other thoughts about this news? I’d love to hear from you.
You cannot decrease weight stigma while saying that the existence of fat people a bad thing (“certainly not good news”), and using terms to describe fat people that are created to medicalize and pathologize fat bodies, adding healthism to the fatphobia.
It’s also impossible to decrease weight stigma while discussing fat people as if they are the charges of thin people ( if…WE want THEM to be healthier, WE need for THEM to be able to be active and present in the community…) I note that you’ve not included the perspective of a single fat person in this piece, choosing instead a disturbingly paternalistic tone.
The Lancet piece you linked to and gave your positive endorsement of is a horrifying example of medical fatphobia, and your piece in “the Conversation” is worse than this piece (the use of the term “obesity stakeholders” stands out) and it is flawed in ways very similar to this piece. Unfortunately, you’ve taken advantage of opportunities given to you by your thin privilege (part of fatphobia being the notion that fat people are to be talked about and at, but not to) and ended up leveraging those opportunities to increase weight stigma rather than center the voices, or even just the perspectives, of fat activists
I’m sure you are well-meaning but if you truly “think the most pressing agenda item is reducing weight stigmatization” (and I agree that it is) then my suggestion would be to center the work of fat activists, and particularly fat activists of color, in this space rather than writing about it yourself, and to embark on a process of self-education. I’m happy to support you in this if you’d like, feel free to reach out.
Hi Ragen —I appreciate your comments and thank you for taking the time and effort to share your expertise and experience. I’ve given this a lot of thought and will continue to do so. You are right that my language of We and Them was wrong on several fronts. I do identify as fat. I am a small fat—I wear some straight sizes and some 1—2X sizes, which I know makes me privileged. I should’ve written clearly from that viewpoint.
In some venues (more academic ones), I write or speak to argue that, even from a standard public health perspective (that does wrongly and harmfully pathologize all of us fat people; it isn’t my perspective), weight stigmatization runs contrary to their interests. When I wrote that the most pressing agenda item was reducing weight stigma, I meant that it followed from the NEJM report—that even from the myopic viewpoint of fatphobic researchers this should’ve been their conclusion. I didn’t state that explicitly, and I am sorry about that.
I want the audiences and authors of NEJM, the Lancet, etc. to change medical research, clinical practice and their own mindsets in what they see as radical ways; of course, we know they aren’t radical at all, but instead informed by evidence and justice and the lived experiences of fat people (like me, like you, like fat people of color, like fat people with differing abilities/disabilities, etc.). I take your points about language (I posted in the past about the word “obesity” as one that needs to be eliminated).
As a small-fat white woman and blogger and academic researcher, I will work to make clearer what my voice is, who I speak for, and who I don’t speak for. I do listen to and read and promote the work of fat activists; I’ll work on doing that more, too. Thanks for your offer of support, and I will be taking you up on that offer; I’ll be in touch. Thanks again.
I appreciate your insights here and fully support your advocacy for destigmatizing of body size and making physical activities accessible to people of all sizes. I also think the darker areas on the maps may represent areas where there are food deserts, where people only have access to highly processed foods. As poorer areas they may also be places where people work two or more jobs to survive and live by buying take-out burgers in bulk and stacking them in the freezer. The above are the cheapest and most convenient ways to eat—sometimes the only ways to eat—in the U.S. and of course companies are thus profiting from the unavailability of fresh, nutritious food.
Hi Mary– yes, I’m sure your insights are correct and apt. Looking at the projected distributions of body weights across US states, we can see a lot of complex patterns.
Those areas are also places where the weather can make people disinclined to exercise. I remember what summer in South Carolina was like–we kids would run around outdoors until about 9:30 am, then we’d go back indoors and emerge after dinner if we wanted to run races or play catch.
And many of those areas also suffer the legacy of moral cretins who closed public beaches and filled in public swimming pools rather than open them to the public–all the public, not just white people. (Actually, the town I lived in also closed their public library.)
Hi Teresa– Thanks for writing! I also remember what summer in South Carolina was like (I grew up there too). Hot hot hot, and yes, horribly racist and segregated and mean in its treatment of African Americans. It’s hotter now, and for a lot of reasons (racism prominently among them), there still aren’t many public places that offer cool, refreshing respite and safe outlets for activity. You’re so right to point out yet another connection between social conditions and health inequities.