Disclaimer: I use fat as a neutral descriptor for mainly plus-sized people. I use the term fat person/people to refer to anyone who identifies as such, and in the context of this article, to anyone who experiences fat stigma or shaming. I choose to use fat instead of BMI terms that often slander and oppress fat folks. Though I do use BMI terms when discussing BMI related research. I choose to use fat instead of any euphemisms, which are often used by those who associate fat with insult and fear. These choices were made in an attempt to not further perpetuate harm.
As we enter the New Year, possibly with re-emerged disordered eating habits from having our family members discuss our bodies over Holiday dinners, it may be a good time to re-visit the “fat-is-bad” trope and the dangers of anti-fat bias.
The scientific debate
Following the declaration of the ‘obesity epidemic’ in 1997, the early 2000s brought us some of the first published cohort studies examining obesity and mortality. The problem? Scientists couldn’t agree if being overweight was bad for you.
In 2004, Fontaine et al. published a Centres for Disease Control and Prevention (CDC) study that found associations between overweight or obesity and mortality in white people. In 2005, Katherine Flegal et al. published another CDC study, showing that compared to people in the normal weight category, overweight people had lower mortality rates and people with mild/moderate obesity had similar mortality rates. Still, both very thin people and very obese people had the highest mortality rates.
Flegal’s paper, perhaps unsurprisingly, caused an uproar in the field as Public Health Officials became concerned the findings might encourage oversimplified conclusions promoting fatness. Fontaine’s paper, though the CDC redacted much of the data due to methodological flaws and just plain ol’ human error, is still citied in diet culture today. Partly in response to criticism, in 2013, Flegal published another study and found that even when adjusting for smoking, age, and sex, overweight people had a lower risk of dying than normal weight individuals.
On the other side of the ring, Dr. Walter Willett, a Public Health and Epidemiology researcher at Harvard claimed the Flegal study was “a pile of rubbish, and no one should waste their time reading it.” Further, Willett and colleagues have published multiple studies suggesting that overweight and obesity are associated with an increased “all-cause mortality.”
Some of the pushback against all of these studies, and obesity research more broadly, is that because the data is taken from previous studies it’s hard to account for people with previous conditions/illnesses or keep track of previous weight statuses, and with Willet’s work, a lot of the data is self-reported. Additionally, all of these studies use the body mass index (BMI) to measure weight, which is problematic in-itself, but is especially inaccurate for most ethnic groups since the original calculations were based largely on data from middle to upper class white men.
Despite these battles, most Scientists tend to agree that being very obese is bad for you and that obesity in general is associated with risk factors, though the causality remains unclear. Scientists also agree that people who are married have lower mortality rates than people who are unmarried. Though again the causality is unclear, speculations include that married people are more likely to receive help if they’re injured, are more likely to be encouraged to go the doctor, and are less likely to experience loneliness which is correlated with adverse mental health outcomes. Why is it that we can rationalize this association, but we’re so comfortable saying that being fat is the problem? Especially given the stigma, violence, and lack of sound medical treatment that accompanies anti-fat bias.
How Anti-FAT bias Harms
Trigger Warning: starvation, racism, violence
Many studies suggest that those experiencing discrimination are at higher health risks due to trauma, stress, and medical barriers. Though fat stigma can negatively impact all areas of life, medical anti-fat bias can be particularly harmful since medical providers have the power to gate-keep healing and health. A study looking at 122 physicians showed that fat patients received office visits that were 30% shorter, and that physicians described these visits as “a waste of their time.” When Corissa Enneking went to the doctor as a fat person on a starvation diet, which had gotten so bad she began missing her period, the physician encouraged her to keep it up.
Hostile treatment of fat patients by doctors can also cause delay in healthcare visits and misdiagnosis. As evidenced by another study, which showed that “obese patients were 1.65 times more likely than others to have significant undiagnosed medical conditions.” Ameema Saeed describes how it took years to get a proper diagnosis of Lupus disease because doctors continually attributed her pain to her fatness.
He managed to denigrate my fatness and blackness in the same sentence
Joy Cox (Hobbes, 2018)
As a teenager, Joy Cox, went to the doctor with stomach pains. Instead of being diagnosed with a severely inflamed bile duct, she was told to stop eating so much fried chicken. “He managed to denigrate my fatness and my blackness in the same sentence,” Cox says. Sociologist Sabrina Strings suggests that anti-blackness and anti-fatness are historically intertwined through 18th century ideas of fatness as evidence of “savagery” and racial inferiority. Colonial ideas of Black bodies being unable to feel pain, and that Black women in particular lacked self-control in both their sexual and dietary appetites reinforced this anti-fat narrative.
Anna Mollow argues that anti-fatness, racism, and ableism can intersect in ways that make fatness the problem; thereby framing any violence as inconsequential. In 2015, Barbara Dawson, a 57-year-old Black woman, sought treatment at a Florida hospital for abdominal pain and difficulty breathing. When healthcare providers were unable to identify the problem they ordered her to leave. Dawson refused, scared for her health. This prompted staff to call the police who would arrest her, ignore her, and watch as she collapsed and died just outside of the hospital. Mollow suggests that Dawson was ‘unvictimizable’ in the ways that health professionals refused to believe she was suffering, and later attributed her death to pulmonary embolism from “excessive overweight,” instead of from the harm enacted by medical anti-fat bias and mistreatment by police and state.
The takeaway
People are complex individuals with other health problems besides the size of their bodies. This makes cause-effect findings in obesity research extremely difficult.
Major systemic factors such as racism, ableism, anti-fat discrimination, sexism, poverty, food insecurity and violence are all powerful de-tractors from health, and individuals experiencing these must also navigate the realities of anti-fat bias present in the medical field. Given this, we might consider that people who are experiencing multiple systems of oppression may be at higher health risks.
Feeding into the fat-is-bad trope contributes to anti-fatness which can cause real and devastating harm. Recognize your biases, think about their effects, and practice compassion.
References
Although most references are linked, here are a few especially helpful ones that shaped this piece.
Bahra, R. A. (2018). “You can only be happy if you’re thin!” Normalcy, happiness, and the lacking body.” Fat Studies, 7(2), 193-202.
Gordon, A “Your Fat Friend.” (2020, December 21). As Coronavirus Rages, We Need to Talk About Medical Anti-Fat Bias. Self Magazine.
Hobbes, M. (2018, September 19). Everything you know about obesity is wrong. Huffington Post.
Hobbes, M., & Gordon, A. (Hosts). (2021, November 16). Is Being Fat Bad for You? [Audio podcast episode]. In Maintenance Phase.
Mollow, A. (2017). Unvictimizable: Toward a fat black disability studies. African American Review, 50(2), 105-121.
Strings, S. (2019). Fearing the Black Body: The Racial Origins of Fat Phobia. New York University Press.
Wann, M. (2009). The fat studies reader. E. D. Rothblum, & S. Solovay (Eds.). New York Unviersity Press.