The Many Dangers of Conflating Weight and Health
It’s day 2 of this newsletter’s launch week and today I’m going to explore a classic mistake healthcare providers (and others) make: the conflation of weight and health.
The concept of manipulating bodies to a “healthy weight” drives a massive amount of healthcare advice and practice, especially for fat patients.
Just one problem…there is no such thing as a “healthy weight.” (Well, two problems - since intentional weight loss fails the vast majority of the time, but that’s a subject for a different post.) People have a certain health status, and people have a weight. These are two separate things. We know that because there are people with the same weight and vastly different health statuses. There are people of vastly different weights with the same health statuses. ‘
As always, a reminder that “health” by any definition is a complex, amorphous concept, and is not an obligation, barometer of worthiness, or entirely within our control.
The idea of conflating weight and health has a lot to do with the use of Body Mass Index (BMI) which is a ratio of weight and height with a racist basis (Please read Sabrina Strings: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrisons Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.)
This measurement became popular with insurance companies who wanted to save money by not having to perform actual tests in order to deny people coverage. Helping them out were diet and pharmaceutical companies who found that if they could convince people that anyone over a certain BMI would have dire health consequences, it was easier to convince them to buy their products.
They got on committees within the CDC and other health organizations, and soon three people with ties to pharmaceutical companies that create and sell diet drugs, in concert with the chief “scientist” at Weight Watchers, managed to convince the CDC to lower what was considered a healthy BMI and then recommend their products as a solution to the problem that they had just created. This process meant that tens of millions of Americans became “overw*ight” overnight, and we were off to the races. The next day newspapers ran the story “Millions of Americans Don’t Know They’re Fat,” but failed to mention that the confusion was because less than 24 hours ago those 25 million Americans had been “normal weight”.
That led to a period before the ACA was passed in the United States (banning insurance companies from using “pre-existing conditions” to deny coverage) when health insurance companies were allowed to use BMI as a “pre-existing condition” for which they were allowed to deny coverage. Fat people continue to be encouraged to undergo a risky major surgery with an extremely poor success rate at 20K a pop, and the diet industry makes over $70 Billion dollars a year. Meanwhile plenty of thin people are misinformed that they are “healthy” simply because of the ratio of their weight and height. The idea of “healthy weight” was and is a mess that does a disservice to people of all sizes, but does more harm to higher weight people and those with multiple marginalizations.
And yet here we are, hearing from everyone and their dog that we need to get to a “healthy weight.” Often, it’s suggested that we should do this by any means necessary, the implication being that it doesn’t matter what wildly unhealthy things we do to get thin, because once we get there we’ll be automatically healthy just because our bodies are smaller.
Except it doesn’t work that way. The best suggestion that doctors can give us when it comes to personal choices is that healthy behaviors are a much better predictor of future health than intentional weight loss attempts. But even that’s not guaranteed. Most of us know someone who followed every health guideline and got sick. Most of us know someone who follows no health guidelines and is healthy as a horse. Marathon runners die of heart attacks at 45 and sedentary Grandmas eat smoke unfiltered cigarettes and live to be 102, because there is a lot more to our health than just our personal choices.
There are healthy and unhealthy people of every weight, shape, and size and I think that the medically responsible thing would be to look at each person as an individual and recommend evidence-based solutions for specific health conditions (from a place of shame-free, blame-free, future oriented care,) instead of trying to stereotype people based on how they look and then trying to find a way to blame them for their health conditions instead of treating them.
If healthcare practitioners were honest with us, they would say that the human body is extremely complex and they haven’t yet scratched the surface of everything that is involved in being “healthy.” They would also ‘fess up that even if they could prove that weight loss makes you healthier (which they can’t) they don’t have a single proven method of weight loss that works long-term for more than a tiny fraction of people. They would tell us that the caloric restriction method (aka “eat less and exercise more”) has an abhorrently poor success record.
I don’t believe that body size is a medical diagnosis, but if a healthcare practitioner is going to treat it like it is, then they have to acknowledge that if “weight loss” was treated like a valid prescription, they would be forced to remove it from the shelves for its complete lack of efficacy and all of its safety concerns. But it’s not, so they just keep recommending the same thing, even though it just doesn’t work.
More and more we are finding that people with similar health habits have similar relative risk of all cause mortality and health hazard ratio (again, with the understanding that a lot more goes into heath than personal choices, and public health should be focused on creating access and removing barriers, not making the individual’s choices the public’s business.)
There are so many things to be improved in this system, one of them is to eliminate the phrase “healthy weight.” No good comes from it, but plenty of harm does.
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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.