Laurie and I are trying to keep this blog generally COVID-19 free, but today I am making an exception. A white friend who is a talented and dedicated amateur epidemiologist forwarded me this interview with Dr. Michael Osterholm, conducted by Dan Buettner at Blue Zones.
Let me be clear: this is generally an excellent article. Osterholm is thoughtful, considerate, compassionate, and knowledgeable. And yet, my friend forwarded it to me because it made them feel guilty, triggered, and more in danger because of the emphasis on obesity as the greatest risk factor for people under 55. Because Osterholm is so clear and careful, they felt especially threatened, and they asked me what I could tell them that would help.
Here’s what I responded.
My basic reaction, with all due respect to Osterholm (which seems like it is a lot) is that this is not something he has thought through. We know beyond a doubt that there is a huge racial disparity in both cases and deaths. You and I know that a lot of the reason for that racial disparity is who is on the front lines and must work and be in contact with the public, whether it’s nurses, grocery store workers, delivery drivers, postal carriers, etc., etc. We also know that there are racial disparities in levels of obesity, and we know some of the reasons for them as well.
I would bet my last dollar that if you correlate that obesity statistic with 1) level of involuntary exposure to the public; and 2) poverty leading to reduced dietary options, the obesity itself would shrink or even disappear. Someone is undoubtedly doing that, because enough doctors of color understand that. But if you are not alert and aware of the correlations between race and obesity, and you are not familiar with health at any size (and most doctors are neither), then obesity looks like a controlling factor. So that’s how I see the science.
The rest of my answer was personal to their situation, and not relevant here. I will say that my answer seems to have provided some relief.
When we learn to look beneath the automatic demonization of fatness, we almost always find that the underlying issues are complicated, racialized, and rooted in many forms of injustice.
When you’ve been doing the same activist work for thirty years and more, it’s hard not to be all “Oh, well, here we are again” when someone new comes out with a hard-hitting article that says all the things you’ve been saying for years.
At the same time, each of these new articles is fresh to the writer, and fresh to many of its readers, and makes a dent in the walls around your ideas. So after one deep sigh, I really welcome Michael Hobbes’ “Everything You Know About Obesity Is Wrong,” published in the Huffington Post.
Hobbes starts with what he calls “scientific myopia,” a quick review of how hard it is to get scientists to step away from their dominant paradigm, and then goes on to make his key point: “Years from now, we will look back in horror at the counterproductive ways we addressed the obesity epidemic and the barbaric ways we treated fat people—long after we knew there was a better path.”
After that, the piece follows what fat activists will recognize as a familiar path: how much social prejudice against fat hurts people, how diets don’t work — I wish he had credited Gina Kolata’s 11-year-old landmark book, Rethinking Thin, which I reviewed as “old news” when it was published — and then gets to his first core point, which is that fat and health are not inextricably entwined. I see that every time I go to the doctor, and the medical tech is slightly surprised at my perfectly reasonable blood pressure, which goes hand in hand with my perfectly reasonable cholesterol numbers. However, Hobbes is good and clear on these points:
individuals are not averages: Studies have found that anywhere from one-third to three-quarters of people classified as obese are metabolically healthy. They show no signs of elevated blood pressure, insulin resistance or high cholesterol. Meanwhile, about a quarter of non-overweight people are what epidemiologists call “the lean unhealthy.” A 2016 study that followed participants for an average of 19 years found that unfit skinny people were twice as likely to get diabetes as fit fat people. Habits, no matter your size, are what really matter. Dozens of indicators, from vegetable consumption to regular exercise to grip strength, provide a better snapshot of someone’s health than looking at her from across a room.
He doesn’t mention the famous “nurses’ study,” which demonstrated that “moderately obese” people live longer than people whose weight is “normal” or “appropriate.”
Next on the roadmap of this kind of article is the issue of medical misuse and abuse, beginning with a profile of a fat victim. Again, Hobbes is clear-eyed and thoughtful:
Doctors have shorter appointments with fat patients and show less emotional rapport in the minutes they do have. Negative words—“noncompliant,” “overindulgent,” “weak willed”—pop up in their medical histories with higher frequency. In one study, researchers presented doctors with case histories of patients suffering from migraines. With everything else being equal, the doctors reported that the patients who were also classified as fat had a worse attitude and were less likely to follow their advice. And that’s when they see fat patients at all: In 2011, the Sun-Sentinel polled OB-GYNs in South Florida and discovered that 14 percent had barred all new patients weighing more than 200 pounds.
Hobbes gives lots of examples of how doctors misuse fat patients, and how they are taught to do so. None of it is new, but all of it is useful fuel for the fire. Then he goes on to the mental, emotional, and social toll all of this takes on fat people, again with real-life stories and useful statistics, and the obligatory quotations from therapists who work with fat patients.
The only place he goes off the rails is in his — often true — argument that
perhaps the most unique aspect of weight stigma is how it isolates its victims from one another. For most minority groups, discrimination contributes to a sense of belongingness, a community in opposition to a majority. Gay people like other gay people; Mormons root for other Mormons. Surveys of higher-weight people, however, reveal that they hold many of the same biases as the people discriminating against them. In a 2005 study, the words obese participants used to classify other obese people included gluttonous, unclean and sluggish.
Of course, this happens. But I personally know so many groups in which fat women gather to discuss our experiences, and to fight the system together, so many blogs, so many websites, so many meetups. I’m sad that Hobbes didn’t find any counterexamples to his theory, and I don’t think he looked very hard. I’d be curious about whether that 2005 study (which, by the way, looked at only 46 people!) would be different in 2018.
Then, he goes to some of the real scientific roots of both increased obesity and increased health issues which don’t relate to weight: issues of the food system. The only thing in the article which surprised me was his claim that people who eat nuts four times a week have statistically significantly lower diabetes incidence and lower mortality. More nuts for me!
Our shitty attitudes toward fat people. According to Patrick Corrigan, the editor of the journal Stigma and Health, even the most well-intentioned efforts to reduce stigma break down in the face of reality. In one study, researchers told 10- to 12-year-olds all the genetic and medical factors that contribute to obesity. Afterward, the kids could recite back the message they received—fat kids didn’t get that way by choice—but they still had the same negative attitudes about the bigger kids sitting next to them. A similar approach with fifth- and sixth-graders actually increased their intention of bullying their fat classmates.
And here he does get to fat activism, although he still doesn’t seem to see that fat activism requires that fat activists like each other and work together. His fat activism quotations are mostly from a journal editor; I’d love to know how many fat activists he spoke to. I’m right here, and I’m hardly alone!
I salute Michael Hobbes for researching and writing this article. I hope thousands of people see it and lots of people share it and discuss it. And I long for the day when the next one of these isn’t in the pipeline somewhere, because the point has been made.
Follow me on Twitter @spicejardebbie . Thanks to @ribbonknight for tweeting this link out.