CW: Talk about the “headless fatty”, discussion of fat stigma and weight discrimination.

Like all reasonable decent people, we at Fit is a Feminist Issue despise those “headless fatty” photos. Samantha and I have blogged about them, and others of us have noted and criticized those discriminatory images as well.

No more headless fatties…

Why the headless fatty photo has got to go…

Fat babies deserve heads

Wow, not even chubby babies get heads these days…

Like a bad penny, these awful images keep turning up.

I’m teaching a course on Philosophy of Food in summer school right now, and we are starting it by talking about food memories, preferences, traditions, rules, violations of rules, and ideals. One of the questions I asked them in a short response paper was about the notion of the “headless fatty” and what they thought about it. Here’s some of what they said:

… the “headless fatty” is problematic because in these pictures the bodies become symbolic. These people are in the photos, but they have no voice, not even a mouth, brain, head, no thoughts or opinions. They are reduced and dehumanized as symbols of cultural fear. The beheaded people in these photographs also symbolize that they are being punished for existing, or they no longer have the right to speak, and that without these people the world would be a better place. 

Yeah. I definitely couldn’t have said it better myself.

Here’s another comment:

[the headless fatty] perpetuates the idea that fat people are not people; that they do not have a brain, a voice, or opinions.

One more, which I really like:

This term is problematic because when you remove someone’s head, they no longer have thoughts or opinions.

YES! It’s so clear to my students that the image of a fat person with no head conveys the idea that they have no agency, no humanity, no intelligence, no voice.

I’m writing this to you because these students are giving me hope that fat shaming and weight stigmatization will dissipate; it’s obvious to them that these images are fat shaming, and also obvious how horrible and harmful that is. Yay students!

Let’s all look forward to a time in the not-distant future where people of all sizes and shapes can hold their heads up high, in part because they have heads. Is this too much to hope for?

Readers, how long has it been since you saw one of these headless fat-shaming images? Yesterday? Last month? Last year? Let us know. I’m really hoping they’re on the wane.

CW: Inclusion of an video that depicts a scene of fat shaming and purports to be anti-fat-shaming, but in fact is fat-shaming. Discussion of body weight, eating, fat-shaming. Mention of the “Karen” phenomenon. Mention of an ableist term and its use.

There’s a new anti-fat-shaming video out there, and it’s very sincere in its attempts to alert people to fat-shaming and to explain why fat-shaming is wrong. Here it is (again, note content warnings above):

The initial scene plays out roughly as follows: A fat woman walks up to the counter of a coffeeshop, orders a kale salad and a small chai tea latte. The cashier– a thin woman– calls her “Fatty” instead of her name, Patty. She also interrogates her about the order in ways designed to fat-shame her. When Patty receives her latte, the name written on the cup is “Fatty”. She runs out of the shop.

Customers in the shop look silently on the scene, no one speaking out, until one man comes up to the cashier. He gives a sincere soliloquy about how the cashier– called, yes, Karen– shouldn’t have bullied Patty.

Here’s where things go wrong:

1. He defends Patty’s right not to be bullied, saying she deserves respect and is trying to change. Change what? Her body size, one assumes. Argh.

2. Then he cites her food choice of a kale salad and small almond milk chai latte as evidence of her desire to change. No, dude. You shouldn’t have gone there.

3. He compares Patty’s state of self to being sick in a hospital, indicating that none of those groups deserve shaming. This is getting really bad really fast.

4. He does go on to connect fat-shaming to stress-eating and point out that studies show that weight discrimination doesn’t “motivate change”. Sigh. This is a more subtle error, but error nonetheless. He’s fully on board with the idea that fat people suffer from fatness and need to be motivated or helped to change. This belief is at the heart of fat-shaming.

5. He uses a ableist word, “lame”, to criticize some views about body image. Gotta be more careful, dude. You don’t want to do more harm here.

6. Here’s my least favorite part: he wraps up his heartfelt speech by entreating the cashier to “accept them for who they are, and lovingly encourage them to be who they could be”.

NO. NO. NO. That is flat-out health concern trolling about body weight. Patty doesn’t need loving encouragement to become something else. Not from her family, not from her doctor, not from her friends, and not from the cashier. What Patty needs is for the cashier to take her order and give her what she asked for in a professional and courteous way. That’s it.

And honestly, I would’ve watched that video and shared it with others.

There are many other flaws in this video, but alas, my blogging time is up. Readers, what did you like or not like about this video? I’d love to hear from you.

CONTENT WARNING: this post is about critiques of the reality show “The Biggest Loser”, thanks to the podcast Maintenance Phase, a fat-positive and evidence-based show debunking junk science and myths about health and wellness fads. Their critiques include information about weight loss, extreme exercise, extreme eating restriction, eating disorders, body dysmorphia and mental health that may trigger or traumatize some people. For those who want to read this post, it is in service of reminding us that fat phobia and all its harmful sequelae are still out there, but so are we. Maybe 2021 will be the year to go full-force against such toxic media. Hence the hope.

Now to the post.

One of the horrors of 2020 that you may have missed (which is kind of a blessing) was the reboot of the horror reality show, The Biggest Loser (henceforth called TBL). For those of us who prudently turned away from this abomination, there are articles to provide background and critique of the show.

The Biggest Loser is coming back– but should it?

Is the Biggest Loser even a little bit better?

‘It’s a miracle no one has died yet’: The Biggest Loser returns, despite critics’ warnings

However, if you don’t have the time or interest to wade through all that, podcasters Michael Hobbes and Aubrey Gordon of Maintenance Phase offer up five things wrong with TBL. Of course there are one million and five things wrong with the show, but: their incisive and humorous analysis gives me hope that more people will turn their backs on TBL and on the social evils that support it.

Here’s their first one: TBL is wildly unrealistic. How so? Here are some reasons Mike and Audrey shared:

1. the kinds of participants chosen for the show were fat people with emotional eating issues, who don’t exercise, and are extremely unhappy with their weight. But, fat people are like all people– some are happier, some less happy; some exercise more, some less; some are happy with their bodies, some less so. Like all the people.

2. The purported method of weight loss: go live in a big ranch house with strangers for months on end, and don’t do anything else. They point out that this method is not found in the medical literature. Good to know.

3. According to the show, the contestants lose an average of 16 pounds/7.25kg in the first week. This rate of supposed weight loss is also not documented in medical studies. Furthermore, Mike and Aubrey tell us that the “first week” is really more like 2–3 weeks, according the contestants. Even so, this is still an unhealthy and unrealistic body change for anyone.

Here’s reason number two: it’s fake and unethical. (that seems like two reasons, but I’m considering it a two-for-one reason).

Case in point: former contestant Kai Hibbard gave interviews about the many ways the producers of TBL would distort results, promote fast weight loss, and otherwise create an environment conducive to disordered eating behavior. Here’s more from this article:

… a runner-up said the show gave her an eating disorder, and seven years later, in a series of 2016 reports, The New York Post quoted contestants who said the show’s doctor and trainer told them to lie about how much they were eating; rigged the weight-ins; and even gave them illegal drugs.

Also, the show features super-processed foods in product placements; TBL has more product placements than any other TV show (533 in 2011).

Reason number three: it’s abusive (and horrible). The contestants are deliberatively portrayed in the most unfavorable way in before pictures, and dolled up to the max in the after pictures. That’s to be expected. But, some contestants have been damned and judged in both their before- and after-weights, some of which are dangerously low according the standard medical science. Further, contestants have reported being encouraged to smoke (to reduce appetite), or pressured to exercise while injured or ill. In the new “wellness” season of TBL, a woman injured her knee doing box jumps, and then is shown using a rowing machine with an ice pack on her knee. No. Just no.

Reason number four: the contestants gain all of the weight back, and suffer permanent harm to their resting metabolic rate. There was a study published here, which you can read about in Scientific American here. Or in the New York Times here. The upshot is that after drastic weight loss, contestants gained a lot of weight back and had a much reduced resting metabolic rate, which the researchers attribute to the drastic weight loss. And this harm isn’t reversible according to our current scientific knowledge.

Last reason, number five: TBL is toxic for everyone of all weights and sizes, blasting false and harmful and distorted messaging telling us: a) what sorts of bodies are the preferred ones; b) that we– the public– can get ourselves one of these preferred bodies; and c) how we can get ourselves one of those preferred bodies. It’s a load of lying lies from a pack of lying liars.

Two other things are worth noting here. First, TBL doesn’t focus on any nutritional information, or talk about cooking, or how to enjoy a greater variety of say, plant-based foods. Oh, no. In fact, the show spends most of its time pushing the contestants to do punishing and painful physical activities, and yelling at them when they are (rightly) tired or or not up to doing them.

For me (and I think for us at Fit is a Feminist Issue), this is (one of) the worst things about TBL: it depicts exercise as a punishment for being fat. And exercise is wholly constituted of activities like box jumps, running on a treadmill, or using a rowing machine indoors. Okay, those things are fine, but what about:

• hiking
• dancing
• yoga
• biking
• swimming
• badminton
• throwing a damn frisbee around with the dog?

Mike and Aubrey make the point that there’s a whole world of fun physical activity, and TBL loser ignores it. Instead, it recreates “the fat kid’s experience of PE”. Great.

Now that I’ve put you all through the wringer of these five reasons why TBL is awful, what’s the positive takeaway?

I do have one. Here it is. The show debuted in fall 2004. It lasted until 2016. In 2020, they tried to resuscitate it and recast it as a wellness show. But it didn’t work– everyone from fitness experts to health columnists to reality show bloggers hated it. We now see it for what it is– a horrible example of our legacy of fat phobia and body insecurity. And those social maladies are not over.

But: no one is talking about how they’re hoping or even considering that TBL is coming back for another season. It’s 2021 y’all. We got no time for that crap.

CW: discussion and critique of an article claiming complex associations between body weight (and other factors) and chronic illness. I use the phrase “body weight” or BMI instead of this term. I’ve written here about why I don’t use that term.

When you’re a teacher, you know that some lessons are harder to learn than others. When I was a student, the subjunctive tense in Italian never quite sunk in (mi dispiace!) I teach a lot of logic, and I know through long experience where the pitfalls lie (e.g. necessary vs. sufficient conditions; a not-very-clear explanation is here, and a really super-long explanation is here). We teachers do what we can, and usually the confusion clears by exam time.

I really wish the same were true with medical researchers and body weight.

In case you missed it, I’m referring to an article published this spring in JAMA Internal Medicine called “Association of Healthy Lifestyle with Years Lived Without Major Chronic Diseases”. The researchers were looking for a correlation between some combo of what they considered to be lifestyle factors and onset of major chronic illness in a database of 116K people, followed for 15+ years. Here are the factors they used:

Four baseline lifestyle factors (smoking, body mass index, physical activity, and alcohol consumption) were each allocated a score based on risk status: optimal (2 points), intermediate (1 point), or poor (0 points) resulting in an aggregated lifestyle score ranging from 0 (worst) to 8 (best). Sixteen lifestyle profiles were constructed from combinations of these risk factors.

Okay, so smoking and alcohol intake are standardly considered to be health-related behaviors– things we do that affect our health outcomes (e.g. what diseases we get and when). Physical activity also has been well-documented to affect health outcomes; however, calling it a lifestyle oversimplifies it, for instance ignoring the many physical and economic and other barriers to activity that are beyond people’s control.

But then we get to body mass index (BMI). BMI is listed as a lifestyle factor? Huh?

Why don’t I think that BMI is a lifestyle factor? Let me turn this over to one of the several responses to the article, published just this week. Authors Kyle, Nadglowski and Stanford write the following:

Treating BMI as a lifestyle behavior obscures the complex etiologies that contribute to BMI… Perhaps more importantly, it promotes a mistaken notion that is the foundation for weight bias and stigma—that [one’s BMI] is [something] that patients choose for themselves through behaviors they elect. The resulting weight bias is well-documented to harm both health and quality of life of patients [with BMI >30].

Body mass index itself is neither a behavior nor a lifestyle, even though health behaviors and lifestyle factors can influence BMI. Many other factors are contributors. 

Yeah, what they said. There are, oh, about three zillion studies showing that body weight is largely genetic and/or heritable (55–70% in many research papers). That means it’s not a health behavior in the way that smoking, alcohol consumption, or physical activity are. Health behaviors affect body weight (just like they affect our cholesterol levels), but that doesn’t make them lifestyle factors, rather they are biological measures used for many purposes.

The original authors (Nyberg, Singh-Manoux and Kivimaki) respond, saying (I’m excerpting but it’s not out of context, I promise):

Maintenance of healthy weight [BMI <25] is indeed part of a healthy lifestyle…

No. Clearly we need to back up and start again.

In this commentary on the article, we get another good try at explaining the situation (this is edited to insert BMI as a term):

Such is the nature of implicit bias about [BMIs >30]. … in their hearts, even some very smart people remain certain that body size must be a matter of choice.

Yes, yes, yes. Very many very smart people (including both the study authors and the editors at JAMA Internal Medicine) still believe that body size is a matter of choice. But it’s not. The replies to this article all cite loads of articles in showing that body size is largely heritable, and if you want some refs, ask me in the comments, and I’ll reply with some standard ones.

So, one last time: body weight is not a lifestyle. But I found this website with 50 lifestyle choices to browse among, if you’re feeling like a change. I claim no responsibility for anything having to do with decisions made on the basis of looking, by the way.

I hope this clears things up.

CW: discussion of research related to body weight, BMI, and weight gain.

While the rest of us have been busy baking bread at home, nutrition researchers have been hard at work keeping dessert science going strong. They’ve been thinking and plotting and measuring and parceling out various amounts of dessert items to various sizes of people, then watching them closely to see what happens.

A group of busy-bee food science professionals released their results this week in an article investigating associations between body weight and milkshake liking. No, that’s not me rephrasing it– it’s the actual title of the article (using the word “ob*sity”, which I strongly dislike for scientific and ethical reasons).

First, they the formed their hypothesis:

(side note: if you’re not familiar with the references in this meme, you’re in for a sweet treat! Start here, then go here. Important: this is not to be confused with the “mikshake duck” meme, which I just learned about one minute ago.)

Back to the meme at hand: that’s not their research question (better to leave it to the “directions for future studies” section). Here’s what they wanted to know:

Prevailing models of obesity posit that hedonic signals override homeostatic mechanisms to promote overeating in today’s food environment.,,Here we define hedonic as orosensory pleasure experienced during eating and set out to test whether there is a relationship between adiposity and the perceived pleasure of a palatable and energy-dense milkshake.

non-science-journal version: they want to know if people’s body weights have an effect on how yummy milkshake consumption seems to them. What they are actually looking for is whether larger people report yummier milkshake drinking experiences (which they think might partly explain their larger sizes). That’s what these scientists are really up to.

What’s next? The researchers set up their test group: 110 people with BMI 19.3–51.2. They asked them to arrive neither hungry nor full, and to have not eaten for at least one hour. The participants came, and waited.

Please note that this study took place before pandemic social distancing protocols were instituted. Otherwise, group size would be strictly limited.

Back to the study: I can’t tell you about the exact methods because even with my awesome library access I can’t get the full article yet. But: the researchers measured hunger before milkshake consumption and also recorded how much the participants said they liked and wanted the milkshake (during consumption).

Finally, we get the results! Here’s what the article says:

We identified a significant association between ratings of hunger and milkshake liking and wanting. By contrast, we found no evidence for a relationship between any measure of adiposity and ratings of milkshake liking, wanting, or intensity.

We conclude that adiposity is not associated with the pleasure experienced during consumption of our energy-dense and palatable milkshakes. Our results provide further evidence against the hypothesis that heightened hedonic signals drive weight gain.

Uh oh! The nutrition scientists got a negative result! They found that body weight had no effect at all on how pleasurable people said their milkshakes were. Keanu pretty much sums it up:

Yes, the study did find a correlation between hunger levels pre-consumption and reported pleasure during consumption. But no one doubted that. And yes, it’s a good thing when scientists get and publish a report on failure to find correlations.

This study gives us a glimpse of something very interesting and a bit worrisome to me, as a fat woman and a health ethics researcher: medical research spends a lot of time and effort searching for causal factors involved in body weight and weight gain that are located in individual persons’ actions, psychological makeups and personal habits. Are fatter people fatter because of something they are doing or feeling or attracted to?

These scientific questions make me uneasy about what may be underlying speculations (or assumptions) by researchers, clinicians and even the general public about what fatter people are doing differently or feeling and acting differently that accounts for their increased fatness. These views are likely yet another source for deep-seated fat-biased beliefs and weight-stigmatizing judgments.

Should we stop doing this kind of research? Even as a public health ethics professional, this is not in my lane, so I can’t say. I think we should remain careful about uptake and reliance on nutrition research, lest it leave a bad taste in our mouths.

CW: discussion of body weight and fat shaming in news and medical writing.

Even in the midst of a global pandemic, some folks manage to carve time out of their busy schedules for fat-shaming, patient-blaming and promoting all-purpose weight hysteria. On April 16, the NY Times wrote this story:

Okay, but what are those “studies”, and what do they “show”?

Here’s the lede, which is rather unpromising:

The research is preliminary, and not peer reviewed, but it buttresses anecdotal reports from doctors who say they have been struck by how many seriously ill younger patients of theirs with obesity are otherwise healthy.

No one knows why obesity makes Covid-19 worse, but hypotheses abound.

It’s worth noting a few key points here: There are no studies. There are preliminary reports, based on gathering some information about some patients in some places. These reports sound similar to anecdotes from medical workers about particular patients who were 1) young; 2) severely ill with COVID-10; and 3) had BMIs>30.

I looked at the report the NYT was going on about. It’s here, and is accompanied by a serious disclaimer:

Good to know. But, just out of curiosity, what’s in there?

The upshot is this: the biggest relative risk (by a factor of 10) for being hospitalized for COVID-19 is age (75 and over for huge relative risk, 65-74 for smaller risk). Smaller relative risk factors were BMI>40 and heart failure. BUT: they didn’t control for race, socioeconomic status or quality of care (according to this article in Wired, and also according to me from looking at the original article).

We do know that it’s not always true that people with higher body weights automatically have higher risks of complications or death when they’re hospitalized for respiratory diseases. Here’s what one study on pneumonia found:

The cohort [of veterans who were pneumonia patients] comprised of 18,746 subjects. Three percent [had BMI <18.5], 30% [had BMI 18.5–25], 35% [had BMI 25–30], 26% [had BMI 30–40], and 4% [had BMI>40]. In the regression models, after adjusting for potential confounders, [BMI>40] was not associated with mortality (odds ratio 0.96, 95% confidence interval 0.72-1.28), but BMI 30-40 was associated with decreased mortality (0.86, 95% 0.74-0.99). Neither [BMI 30-40] nor [BMI>40] were associated with ICU admission, use of mechanical ventilation or vasopressor utilization. BMI <18.5 patients had increased 90-day mortality (1.40, 1.14-1.73).

The only group with increased mortality risk was the BMI<18.5 group. The other BMI groups either had a lowered risk or a non-increased risk.

Of course, this is only one study, but there are a lot of studies that fail to show a connection between higher body weights and risks of complications and death during hospitalization for some respiratory illness.

Other investigations are at ongoing and at various stages of revision and peer-review. This is important, as one thing we know for sure is that trying to tease out the influence of one feature of patients on particular health outcomes is very very hard. Small sample size, lack of representativeness, potential confounders and methodological flaws all get in the way of reliable results. Wired gives a good and detailed analysis of ways that some claims about the relationship between BMI and COVID-19-related health outcomes are unwarranted. And they offer a possible explanation:

The fact that researchers have been pointing to body size as a risk factor for weeks now, even in the absence of much evidence, is a clear example of how weight stigma gets enacted in science.

I don’t work in medicine, but I do know that there is a humongous evidence gap between what’s happening clinically in a particular hospital and its patients (each with their own complex medical and other histories), and what is true about everyone with higher BMIs in the US (not to mention other countries) with respect to risks related to COVID-19. Right now we can’t say much of anything. So maybe we shouldn’t. Which means the answer to my blog title question is, “we don’t have evidence right now to answer this question”. It doesn’t make for exciting news copy, but it’s the closest thing to the truth right now.