What's Wrong With Fat? (27 page)

Collectively, these results suggest that news reports on the “obesity epidemic” intensify anti-fat stigma but that it is more difficult—in a society so saturated with anti-fat messages—to lessen anti-fat prejudice or promote size diversity as a positive value. To the extent that news reports, including those on the Fat-OK study, still emphasize health risk associated with obesity and discuss personal responsibility, they may be too closely aligned with people’s preexisting negative attitudes toward fatness to shift ingrained anti-fat attitudes.

While the effect of reading one or two articles is arguably short lived, most Americans today are bombarded with a constant stream of narratives about body size, most of which frame fatness as a public health crisis brought on by bad personal behavior. While people are wringing their hands about growing “obesity rates” and the social ills driving and resulting from them, they are not considering the social consequences of this barrage of fat frames. The rest of this chapter broadens the discussion of the material consequences of specific fat frames. As we will see, the stakes, in terms of human suffering and public health, are huge.

WHAT MEDICAL FRAMES DO

Received wisdom suggests that, to solve the “obesity epidemic,” doctors must tell their patients that they are at an unhealthily high weight and provide them with weight-loss advice. 19 There are surely cases in which being told by one’s physician that one is at an unhealthy body weight leads to positive behavioral changes that result in weight loss. This is especially likely in people whose weight is atypically high for them because they have become inactive or developed unhealthy eating patterns. For these people, a doctor telling them to lose weight for health reasons may be motivating and productive.

However, in cases in which a patient has struggled and failed to lose weight, being told that her or his body size is inherently pathological can be harmful. This was precisely the experience shared of a leading fat acceptance activist, whom I will call Nicky, who shared her story with me.
At the beginning of her first consultation with a new gynecologist, the physician suggested that Nicky lose weight. Nicky confidently replied that she was part of the “size diversity community” and that her “weight is not up for discussion. I’m very happy with who I am and what I look like.” According to Nicky, the doctor “[waited] till she puts the speculum in and [then] decided to start telling me about estrogen levels and [that] obesity leads to diabetes.” For some women, being in gynecological stirrups is, as Nicky puts it, “the most vulnerable [physical] position you would ever be in in your life.” She says she felt disbelief that this doctor was “actually doing this” and trapped, since she could not “jump up off the table.” She said she “just kind of went somewhere else.” Despite being “a size acceptance advocate,” Nicky says it took her a month to be able to “get her head around what [the doctor] just did to me” and to write a letter of complaint to the doctor, the head of the clinic, and the state. Nicky says she “can’t imagine” how traumatized someone who had not been involved in the fat acceptance movement would have been.

University of California–Los Angeles PhD candidate Kjerstin Gruys similarly recounts on her blog “Mirror, Mirror... OFF the Wall” how participating in the National Health and Nutrition Examination Survey (NHANES) as a research subject was psychologically trying, albeit on a smaller scale. 20
Gruys was initially thrilled when she was chosen at random to participate in the survey, as she was intimately familiar with studies based on this dataset and with conducting her own research on body size. Gruys found the various required medical exams and surveys fascinating. She received an outstanding bill of health on every item with one exception: her “Body Measurements” (i.e., her BMI and waist circumference). At 159.8 pounds and 5 feet 5 inches tall, her BMI was 26.5, in the lower range of the current “overweight” category. Her waist circumference, at 36 inches, was 1 inch above the recommended maximum. As a result, she was warned that she faced “an increased risk of health problems such as type 2 diabetes, high blood pressure, and cardiovascular disease.” Gruys described how this information evoked feelings of shame, despite the fact that she was intimately familiar with the Fat-OK study. Ironically, this study’s findings that those in the “overweight” BMI category have the lowest mortality rate of any other BMI category were based on analyses of the NHANES data. 21 She writes that she “struggled for several days to banish the urge to go on a crash diet.” Given her history of anorexia, which she openly discusses in her blog, these reactions were potentially quite dangerous.

This anecdote also raises the question of whether telling healthy people that they are at risk for various illnesses might become a self-fulfilling prophecy. This is a hypothesis currently being explored. Scientists refer to this as the
nocebo effect
, which functions as the inverse of the better-known placebo effect. Whereas the placebo effect refers to how an expectation of a treatment having a positive outcome itself causes symptoms to abate, the nocebo effect refers to how an expectation of a negative outcome leads to the worsening or developing of a medical symptom. 22 Moreover, in that treating fatness as a form of medical pathology that people bring upon themselves conveys hostility and hatred to fat people, such messages may worsen their health by increasing their stress. There have been several studies showing that medical professionals have negative attitudes about their fat patients. 23 There is also work showing that racial discrimination and the stress that it creates for African Americans is one reason this population tends to have worse health outcomes than American whites. 24
This opens the possibility that something similar could be at work for fat people, in which weight-based discrimination and stigma, rather than or in addition to any physiological effects of high body mass, lead to ill health. 25

Lending support to this line of argument, drawing on the 2003 Behavioral Risk Factor Surveillance System data (N = 247,027), public health scholar and MD Peter Muennig and his colleagues have found that people who are unhappy with their current weight and are trying to lose weight are more likely, regardless of their actual weight, to have more weight-related illnesses. 26 There is also evidence that people who experience weight-based stigma are more likely to suffer from depression and to engage in binge eating. 27 Moreover, several studies have shown that youth who experience weight bias are more likely to avoid physical activity. 28

Experience of stigma in health care settings may lead people to delay or forgo essential preventive care. Indeed, several studies have shown that people with a BMI over 30 are less likely to undergo age-appropriate screenings for breast, cervical, and colorectal cancer. 29 Some reasons heavier women give for delaying and/or avoiding preventive care include having gained weight since their last visit, not wanting to be weighed on the doctor’s scale, not wanting to undress in the exam room, and knowing that they would be told to lose weight. 30 One study of more than 6,000 obese white women found that the primary reason that obese women were more likely than “normal weight” women to avoid cervical cancer screening was embarrassment or discomfort. 31 In a study of women with a BMI over 55, 68 percent reported that they delayed seeking health care because of their weight, and 83 percent said that their weight was a barrier to getting appropriate health care. When asked specifically about the reasons for delaying care, women reported disrespectful treatment and negative attitudes from providers, embarrassment about being weighed, receiving unsolicited advice to lose weight, and gowns, exam tables, and other equipment being too small to be functional. The percentage of women reporting these concerns increased as BMI increased. 32

Some fat patients who do seek medical care say that doctors assume any ailment is due to their body size and will not perform on them the medical tests that are routinely performed on thinner patients. One study of 161 adults with a BMI of 30 or greater attending dietetic outpatient clinics in the United Kingdom found that 84 percent of respondents agreed that “weight is blamed for most medical problems.” 33 This is a common complaint with members of fat acceptance groups. 34 As fat acceptance activist and National Association to Advance Fat Acceptance (NAAFA), leader Frances White puts it to me in an interview:

If we go to the doctor with the presenting symptoms of strep throat, we get a doctor saying to us, “Well you know you wouldn’t have so many strep throats if you just lost fifty pounds.” Absurd. If you go to a doctor because your knee is bothering you, the doctor will say, “It’s obviously an orthopedic problem brought on by your weight.” But have you done an MRI? Have you done any sort of x-ray to see if maybe there’s torn cartilage or something? No. There’s just the assumption based on your size that you have this medical condition and only losing weight will fix it.

These assumptions combined by lack of accommodations for larger bodies lead many to feel devalued by the medical establishment. “If people really were concerned about the health of fat people, we’d be able to get health insurance, there’d be [hospital] gowns to fit us, there’d be tables to support us, there’d be equipment that [accommodates our bodies],” says fat liberation activist Marilyn Wann.

The focus on fatness as medically harmful and inversely on weight loss as the solution for all woes can lead researchers and clinicians alike to miss important information that does not fit this frame. So, for instance, psychologist Deb Burgard spoke in her 2007 keynote address at a joint annual meeting of the Association for Size Diversity and Health (ASDAH) and NAAFA that doctors will not conduct sleep studies on patients who are thin because they only associate conditions like sleep apnea with being fat. She notes that she has found in her own clinical practice and has heard from other clinicians that many of the children with sleep apnea who are not fat are misdiagnosed as ADD and ADHD. Specifically, she recounts that “sleep apnea is so linked with fatness that when I sent one of my anorexic patients to be tested for sleep apnea, and she was indeed diagnosed with it, the sleep medicine department sent her a letter advising her to ‘consider weight loss.’” That one could advise weight loss for an anorexic patient drives home the way in which frames obscure information that is inconsistent with their basic assumptions.

Drawing on the NHANES 1999–2004, an epidemiological study estimated that the proportion and number of people in the “normal weight,” “overweight,” and “obese” BMI categories that were metabolically healthy or metabolically abnormal, based on six measures of cardiometric abnormalities: elevated blood pressure, elevated triglyceride level, decreased HDL-C level, elevated glucose level, insulin resistance, and systemic inflammation. 35 They found that 23.5 percent of people in the “normal weight” category, or 16.3 million people, have an abnormal cardiometabolic profile, whereas 51.3 percent of people categorized as overweight (35.9 million people) and 31.7 percent of those categorized as obese (19.5 million people) have normal cardiometabolic profiles. This suggests that using BMI as a proxy for cardiometabolic health, in which “normal weight” people are considered healthy and the “overweight” and “obese” are assumed to be unhealthy, may lead doctors to overlook as many as 16.3 million (“normal weight”) people who have abnormal cardiometabolic profile while
over-treating
55.4 million (“overweight” and “obese”) people who actually have normal cardiometabolic profiles. This is costly, both financially and in terms of health.

Gruys writes about how unquestioned assumptions—of fatness as unhealthy and of weight loss as good—shape the production of scientific knowledge (and ignorance). According to Gruys, during her home visit, the field interviewer asked her if she had “ever participated in any weight-loss diets.” She answered that she had. The interviewer then asked, “How much weight did you lose in your most successful weight-loss attempt?” The very wording of this question implied that weight loss is always a healthy endeavor. In fact, Gruys’s most successful, as defined by greatest, weight loss was when she lost what she calls a “horrifying and unhealthy” amount of weight because she was anorexic and “could have died” as a result. She further notes that “despite asking [her] to describe, in detail, every bite of food that [she had] eaten in the prior 24 hours, [she] was never asked whether [she had] purged any of this food, or if [she] had taken laxatives or diuretics.” Gruys points out that “through these questions (and non-questions), some of the most dangerous health behaviors—such as crash-dieting, purging, laxative abuse, and extreme food restriction—are made invisible.” 36

WHAT PUBLIC HEALTH CRISIS FRAMES DO

We have already discussed how framing fatness as a public health crisis makes obesity researchers more competitive in contests for research grants from private and federal funding foundations, on which they depend for a large portion of their own salaries and the salaries of their staff. The sense of
obesity
as an epidemic and public health crisis also provides a strong argument to increase funding of the CDC, the NIH, and other government agencies. 37

Talk of an obesity epidemic may have interpersonal ramifications as well. Arguments about obesity spreading like a contagious disease through social ties may make people even more likely to befriend people who are thin, rather than fat. 38 Indeed, while not explicitly telling readers to shun their fat friends, an author of one such study was quoted as saying that “if [people are] interested in losing weight, forming ties with people who are the proper weight is likely to be beneficial.” 39

Furthermore, announcing a public health crisis and evoking an epidemic has historically lent a sense of urgency that can—like declaring war—justify abridging civil liberties (think quarantine). Indeed, the framing of fat as an impending health disaster has been used as justification for the “war on obesity.” This “war on obesity” has unfolded simultaneously with the “war on terror” and has mirrored it in interesting ways. Following the terrorist attack that destroyed the Twin Towers in lower Manhattan, former Surgeon General Richard Carmona, famously called the obesity epidemic the “terror within” and predicted: “Unless we do something about it, the magnitude of the dilemma will dwarf 9–11 or any other terrorist attempt.” 40
At the 2001 launch of the “national plan of action” in response to obesity, former Secretary of Health and Human Services Tommy G. Thompson urged “all Americans [to] lose 10 pounds as a patriotic gesture.” 41 Meanwhile, journalists have compared nerve gas to “stockpiles of sugar, salt and fat [that are] slowly immobilizing our children” and have cast dieters as “foot soldiers in the war against obesity.” 42