Being the fat kid is something that never really goes away. When you spend your every waking moment acutely aware of the judgmental tone of every glance thrown your way, it leaves an indelible mark on who you are that is hard to erase. You can be a fat adult — comfortable, proud — and still, in the back of your mind, be thinking about coming in last on the athletics track on a hot summer day, thighs chafing, while your schoolmates point and laugh.
The shame is real.
Fatness is one of the few culturally accepted biases in our society. Being publicly fat is, as I can attest, an exercise in self-hatred and castigation. And recently, people have been making the wonderful argument that, instead of treating fat people as sub-human beasts, we should try and reduce the horrifying stigma that they face.
This is all to the good.
Unfortunately, there is another extreme that is being embraced by some. The argument that “obesity isn’t the problem!” is becoming more and more common. It would be wonderful for all of us if obesity was not the health problem that we think it is.
Sadly, this is just not the case.
Obesity is absolutely bad for your health.
That does not mean that shaming people is ok.
The argument that obesity is actually not a health issue comes from a fascinating phenomenon that epidemiologists started noticing a couple of decades ago. If you look at health issues — in particular all-cause mortality (when people die for any reason) — and plot the risk on a graph, you find that very fat people do really badly. But people who are just a little bit fat — with a BMI of 25–30 — often actually do better than people with a supposedly ‘healthy’ BMI.
Now, this link has long been explained. It turns out that, when you control for demographic factors, this relationship largely disappears. People who have a slightly high BMI tend to be wealthier, more university educated, smoke less, drink less, and have a lot of social benefits that make them just a bit healthier than people who are a ‘healthy’ weight.
But this paradox led to an important question: what about metabolically healthy obesity? What we mean here is people who are obese but with no health problems — like heart disease, or diabetes — that we commonly see linked to obesity. This group of people is large, with up to two-thirds of obese people having no metabolic issues.
So, scientists decided to look into metabolic health, which includes things like fitness and blood pressure. And they found something remarkable.
It turns out that metabolic health is actually more important than weight.
But, importantly, the research does not show that obesity is healthy. Metabolic health is more important, yes, but obesity is still worse for you than being lean. People who have poor metabolic health are at about double the risk of heart disease as people with good metabolic health, regardless of weight, but people who are heavier have even worse outcomes.
We also know that obesity causes any number of health problems. Usually these large studies only look at all-cause-mortality, or heart disease, but obesity also makes things like arthritis, dementia, and breathing difficulties worse.
What doesn’t kill you can still make your life pretty uncomfortable.
What Do We Do?
This is where most theories diverge. We know that obesity is bad for you: it’s been proven again and again. But what to do about obesity, that’s a far harder problem to solve.
Some people think shame is a good solution: “Tell all the fat people that they’re killing themselves, and they’ll be motivated to lose weight!”, as if this was a new and innovative strategy.
It is not.
Shame, it turns out, is extremely bad for you. There is a popular myth that you can get people to make their lives healthier by shaming them into it, but the reality is that shame is associated with a greater risk of depression while not actually impacting clinical outcomes — particularly obesity — very much at all.
Weight stigma is very real, very painful, and causes enormous problems. The internet is now filled with some spectacular writing cataloging the innumerable scars caused by the stigma and shame that comes along with being a few sizes too big to be socially acceptable. There are also vast libraries filled with research demonstrating that, perhaps counterintuitively, shame does not actually make people healthier.
It turns out that most of the solutions to our societal obesity problem appear to be social. Things like taxation, regulation, changing the environment to make exercise easier, even seemingly unrelated things like social support payments, are all much more likely to help people lose weight than shaming them.
Ultimately, we know that obesity is a problem. Not all obese people get sick, but not all smokers do, either. It is a risk factor like any other.
But what we do about it? That is a much harder thing to solve.
The only thing we absolutely do know is that shame does not work.