Does size really matter for our health?

Posted by Peter van der Graaf, AskFuse Research Manager, Teesside University

A friend of mine recently posted on Facebook a story from a so-called “professional fatty”. In her story published in the New York Times, Sarai Walker took issue with what she called ‘obesity bias’: obese people being portrayed as the baddies. Or as Sarai herself puts it: "Even the most open minded critical thinkers become outraged if fat is spoken about in any positive way: a person can never be simply fat, a fat body always needs to be fixed”.

Instead she argues that the most significant problem for fat people isn't their bodies but the hatred and abuse they receive from society. And she is not alone in this thinking: protest movements have captured the attention of the media by rallying against what they describe as the narrowly focused weight based approach to health. An example is the Health at Every Size (HAES) movement. HAES proponents believe that health is a result of behaviour that is independent of body weight. This is a pretty bold statement that can easily be disputed with research evidence but that is not the point here. The point is that these protest voices chime with a lot of resentment at evidence-based public health messages. Sure enough, another friend joined the debate quickly on Facebook proclaiming her anger on the occasion that her daughter came home from school with a book saying sugar is bad. Public health’s head was once again on the block as the kill joy of everything good and fun and therefore worthy of disputing.

Picture courtesy of  Anna Deflorian/The New York Times

But if we keep getting the message wrong what do we achieve in the end with our evidence-based message? And what is the right message? Should we go along with the ‘Health at Every Size’ claim and focus instead on how to make life more enjoyable at every size? After some highly scientific browsing on Google I came across an article from David Katz, Director of the Yale University’s Yale-Griffin Prevention Research Center, in the Huffington post, which from its catchy title: “Why I can't quite be ok with 'okay at any size' appeared to promise an answer. David Katz also opposes obesity bias; he rejects the notion that widespread obesity among children and adults is somehow due to “an inexplicable global outbreak of personal responsibility deficiency syndrome”. Where he does not agree with HAES is the complete decoupling of weight and health: he is ok with any size if it includes a proviso: as long as health is not adversely affected. Flab is not always fab, he argues, and as a society we should not want to normalise ill health or the factors that impose it.

When I pointed this out to my friend on Facebook, her response was that these were two separate but related issues: one is that obesity carries health risk, which was a matter for the individual and perhaps their doctor. The other was the issue of stigma of obesity under the guise of concern for one's health which is a society problem. But is this really true? Should we define obesity as a private matter that is none of society’s concern and focus instead on developing a culture where people of all sizes feel accepted no matter the risk to their health?

The arguments and evidence presented by both proponents and opponents of the Health at Every Size seem to suggest to me that weight is as much a society/cultural issue as an individual behavioural choice. Hence the emphasis in Public Health on Whole Systems Approaches to Obesity and the impressive Obesity System Influence Diagram, developed in 2007 by the Foresight Project researchers. And perhaps therein lies the problem: if obesity is a complex issue at both individual and societal level (and not just complicated) we cannot simply choose one over the other (accepting fat as an individual’s prerogative for happiness or obesity as societies overriding health responsibility). We also cannot ignore the individual health risk of overweight and obesity but cannot accept the stigma we attach to individuals for failing to be thin. Instead, we might need to find new public health messages that frame individual choices in a cultural framework, for example: “You can be fat and fit but few of us are so why not try together to be a bit fitter?” Maybe it’s not the size but the message that matters more for our health.

Picture attribution: Artist - Anna Deflorian, used in Sarai Walker's article "Yes, I'm Fat. It's O.K. I said it" Feb 6 2016, The New York Times.