As you are all aware by now, I believe that weight loss isn’t the answer. One of the questions I get asked the most is “surely there comes a point when a person’s weight affects their health”? And boy is that a loaded question, because it can be interpreted in so many different ways. Are you asking me whether the rules about Health At Every Size have a cutoff? Are you simply trying to figure out ‘how big is too big?’ What exactly are you asking me here because the answer very much depends on it?
Rather than trying to respond to this question with a simple yes or no, I’m going to spend some time exploring three really important concepts that I believe we all really need to come to terms with:
- Fatness is not a diease
- Weight loss isn’t the answer
- If weight loss isn’t the answer, what is?
Fatness is not a disease
I have said in the past that I do not believe that ob*sity is a diease. It pathologises fatness. Is baldness a disease? Nope. According to the Oxford Dictionary, a disease is a “disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury”. Merriam-Webster describes it as “a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms”. And finally the Cambridge dictionary describes it as “an illness caused by infection or a failure of health rather than by an accident”.
The difference between health and lifestyle
Being fat is not a disorder of structure or function of the human body. It does not cause any symptoms. It’s not an illness or a failure of health and we’ve got to stop thinking of it that way. “But surely you admit that fatness can impair health”? Well that’s a tricky question, isn’t it. For starters you have to define health, and that isn’t an easy thing to do.
Then you have to show me how fatness impairs it. I suppose you could make an argument that fatness impairs function in some people. I once spoke to a man who put it very bluntly. He said “at one stage I was incapable of wiping my own backside”. And that made me stop and take note. I suppose it is possible for your body habitus to impair your function, but I always supposed that this was something that could be fixed by improving flexibility or stamina rather than just by losing weight.
Weight loss isn’t the answer
The problem with labeling fatness as a disease is that people assume that there is a cure, and that the cure is to reverse it. Which is completely unfounded for so many different reasons.
Being fat does not reduce your life expectancy
Most studies find that people who are “ov*rweight or moderately ob*se” live at least as long as normal weight people, and often longer. Yup, you heard me. There’s also one brilliant study that shows that the optimum BMI for long life is significantly higher in black men and women than it is in white folk. Which demonstrates what we have been saying all along. BMI is racist and now you know why.
Check out the conclusion to one study:
Compared to those in the “normal” weight category, neither overw*ight nor ob*sity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overw*ight (hazard rate ratio = 0.83) and those who were ob*se (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status. Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58).Socioeconomic and behavioral risk factors for mortality in a national 19-year prospective study of U.S. adults (Lantz, 2010)
Being fat does not CAUSE disease
I’ve said it time and time again, but association is not the same as causation. The vast majority of studies that show an association between a condition and body mass do not adjust for really important confounding factors. Things like fitness levels, diet quality, family history, economic status or weight cycling. The latter is really important.
Weight cycling is more common in fat folk, because we are the ones that are constantly being advised to lose weight. But weight cycling is known to increase inflammation, increase blood pressure, increase cholesterol levels and result in insulin resistance. Any of this ringing a bell here? These are often the reasons that are cited when people talk about how dangerous fat is for your health.
Yet the findings from some of the largest epidemiological studies that people often point to when discussing weight and poor health actually demonstrate that once you adjust for weight cycling, the association between so-called ‘ob*sity’ and poor outcomes disappears. This paper sums it up:
Most epidemiological studies estimating the relationship between body weight and mortality do not control for fitness, exercise, diet quality, weight cycling, diet drug use, economic status, or family history. Furthermore, in studies that control for some of these factors, the data are usually self-reported and thus of extremely questionable reliability. (See, for example, the five-point exercise scale used in the Nurses’ Health Study.) By contrast, when one or more confounders are controlled for in a rigorous fashion, the already weak association between higher body mass and greater mortality tends to be greatly attenuated or disappear altogether. For example, all of the excess mortality associated with ob*sity in the Framingham study can be accounted for by the impact of weight cycling. Ob*se Framingham residents with stable body weights were not at increased risk. The same result has been obtained in NHANES.The epidemiology of overweight and obesity: public health crisis or moral panic? (Campos, 2006)
Weight loss does not prolong your life
In actual fact, weight loss shortens your life expectancy. Yup, you heard me. There are several studies that show this. This is particularly relevant in extreme weight loss:
Weight loss of 15% or more from maximum body weight is associated with increased risk of death from all causes among overweight men and among women regardless of maximum BMI.Weight loss from maximum body weight and mortality: the Third National Health and Nutrition Examination Survey Linked Mortality File (Ingram, 2010)
Look, there is no question that there a number of short-term weight loss intervention studies out there that show improvement in health, but that is because the weight loss is always accompanied by a change in behavior. But there is no real evidence to show that these improvements are down to the weight loss itself as opposed to the behavioral changes.
If you look at diabetics, for example, the improvement in their blood sugar control takes place in a matter of days, long before there is any significant weight change. One study that followed up diabetic patients on four different weight loss interventions found that weight loss didn’t really improve their blood sugar levels. Yet almost all diabetic practitioners focus on weight loss as a primary goal.
Studies that do show improvements in health outcomes with weight loss almost always demonstrate that very modest amounts of weight loss (around 5% of body weight) demonstrate just as much improvement than more significant losses. So if weight loss really is the cure that everyone assumes that it is, why doesn’t it improve your health with every pound that you lose?
Weight loss doesn’t actually work
Fact. Weight is almost always regained within 3-5 years. More recent studies show that up to two thirds of individuals regain more than they started. Studies on post bariatric patients are beginning to demonstrate that weight loss peaks after the first year followed by a slow but steady gradual increase.
Fact. Dieting has a whole host of negative consequences. Weight cycling is dangerous (see above). Weight loss is associated with osteoporosis, meanwhile being fat generally protects you from bone thinning. Chronic dieting increases your cortisol levels which is associated with poor health outcomes. And as I have mentioned in previous posts, dieting leads to poorer health outcomes, negative body image and disordered eating. The UK house of commons recently published a report that supports this.
Fact. Prescribing weight loss is associated with weight stigma. Both institutional forms of anti-fat bias and interpersonal mistreatment due to body size are extremely common and “in some cases were even more prevalent than discrimination due to gender and race” (Puhl, 2008). Stigmatising people decreases their motivation and leads to binge eating, avoiding exercise and postponing medical care.
So we’ve taken a look at the evidence. What about individual risk? Is it possible to measure this?
Why yes, yes it is. For example, we are actually able to predict your cardiovascular risk fairly accurately. In the UK, we use something called the QRISK score, and there are similar scoring systems in other countries too. Doctors use this scoring system to decide how to treat you in order to prevent a heart attack or a stroke. Should we treat you cholesterol? Should we refer you to a specialist? Check the QRISK.
So how about we do just that.
Let’s start off with a 50 year old White British woman who is a non-smoker, not diabetic, has a perfect blood pressure and perfect cholesterol. We’ll call her Jane. If I put all her data in the Q-Risk calculator, I calculate her 10 year risk of developing a heart attack or a stroke as 1.7%. Unsurprisingly it is very low. Anything less than 10% is considered low risk, and it is well known that women in their 50s are fairly low risk, especially if they are in good health.
Ethnicitiy and smoking
If we make Jane Indian, her risk still remains low but it increases by 0.6%. Now this may not seem very impressive to you, but if you think about it, this is 25% higher than Jane’s score. So ethnicity has an impact on our individual score.
What happens if we make Jane a moderate smoker (10-20 a day)? Her risk goes up by 1.5%. In other words, it almost doubles! Again, 3.2% is still a low score, but it is significantly higher than if she were never to have smoked. You see, there are a number of things that can impact our personal risk of developing a heart attack or a stroke, and it is important to recognise this.
Medical History and medication
There are certain medical conditions that are associated with a higher risk. Let’s take Migraine. If Jane happens to suffer from migraines, her risk goes up bu 0.5%. It still remains low but it actually goes up by 23%. The same goes for Rheumatoid arthritis or Lupus (SLE). If Jane happens to be a schizophrenic who is taking antipsychotics, it goes up by 0.8%. In other words, her risk increases by a third.
Now I made Jane a woman because I know that women are at much lower risk of heart disease than men. But what happens if we turn Jane into John for a moment. I’m not suggesting she is transitioning here. I mean let’s just click the ‘male’ button rather than the ‘female’ one. When we do, the risk goes from 1.7% to 3.3%. It essentially doubles, thus proving that women are the far superior sex! Just kidding.
So far, we’ve learned that ethnicitiy, smoking, certain medical conditions, medications and gender all play a role in our risk of heart disease. So now let’s talk about the o-word. Let’s make Jane fat. We’ll take her from a BMI of 23 to a BMI of 40 (gasp!) What do we think her risk is going to be? Higher than smoking? Probably not. We all know smoking is the highest risk. But higher than migraines and rheumatoid arthritis, surely? What about ethnicity? Do you think being fat poses more risk to your health than being from the South Asian Subcontinent?
If we give Jane a BMI of 40 and keep the rest of her levels the same, just like we did with all the other examples, her risk increases by a mere 0.4%. That’s less than a 20% increase and is actually the smallest risk factor for heart disease in a 50 year old White British woman who is a non-smoker, not diabetic, has a perfect blood pressure and perfect cholesterol. Lower than migraine, rheumatoid arthritis, and significantly lower than smoking.
But that can’t be right!
I know a lot of you are shocked right now. That is certainly not what you have been led to believe, is it? But that is the difference between population risk and individual risk. When people say ob*sity is the second biggest killer in the UK today, what they mean is heart disease is the biggest killer in the UK and of all the people that die of heart disease a large number of them are fat. And we have attributed their fatness to their heart disease even though we will never know for sure if that is the case.
No one ever blames migraine for heart related deaths! Nor do they blame blood pressure. But if we were to give Jane a slightly raised blood pressure, her risk goes up by a third. The reality is that most people die because they get older. Once Jane turns 60, assuming she has managed to stay in good health, her weight doesn’t change in spite of the menopause, and her blood pressure and cholesterol remain normal, her risk has gone up by 62%. It still remains low, but time marches on and so does our risk.
Is the risk reduction worth it?
Please note that if fat Jane were to stay exactly as she is, her risk would go up by the exact same amount. So it’s not like being fat makes things worse over time. Now lets put this in to context, shall we? ‘Perfect’ Jane’s risk of a heart attack at the age of 50 is incredibly low. So low that I would call it negligable. So is Fat Jane’s risk. The difference between their risks is a mere 0.4%.
The difference between their weight is 56kg. That’s 123lbs. Can we just take a moment to let that sink in? Can you even begin to imagine what it would take to lose 123lbs? That’s basically a whole person (a really thin person but still). So you have to ask yourself, is it worth it? Are you prepared to go through the hell of dieting knowing what you know now?
Me neither. Weight loss isn’t the answer. I don’t care how big you are. Evidence is evidence and it is time we stop ignoring it.
So if weight loss isn’t the answer, what is?
That’s a good question! Almost everyone works off the assumption that weight loss is the only way to improve your health if you’re fat. But the reality is that no one knows this because it’s never once been tested. In order to show that weight loss improves health, you can’t just compare rates of certain diseases within the population and demonstrate that it is higher in fat folk than it is in others. You have to test the hyopthesis. You have to do a study that shows that losing weight actually benefits your health. And those studies simply don’t exist.
Why? Well to start with, the majority of people regain their weight so it is impossible to test the long term implications on their health. As I said earlier, some studies show a short term improvement in health which can be attributed to the behaviour change as opposed to the change on the scales. Also, Lifestyle interventions have been shown to improve a number of conditions irrespective of weight loss.
One study looked at the effect of aerobic exercise on insulin resistance. It showed an improvement in insulin sensitivity in all the patients observed even though there was no reduction in body fat mass. That flies in the face of all the experts who claim exercise only benefits your health when there is a reduction in body fat and increase in muscle mass. The study had its limitations but it is still an interesting concept and I like the fact that we are beginning to challenge these widely accepted beliefs.
Health At Every Size
Most of the information that assisted me in writing this blog post comes from a comprehensive review of the literature written by Lindo (formerly Linda) Bacon and Lucy Aphramor. The article is entitled “Weight Science: Evaluating the Evidence for a Paradigm Shift” and I cannot recommend it enough. If you’re a healthcare professional or you’re just interested in the evidence, I urge you to read it.
The article contains a segment entitled “Health at every size: shifting the paradigm from weight to health”. It “explains the rationale supporting some of the significant ways in which the HAES paradigm differs from the conventional weight-focused paradigm”. The following topics are addressed:
The three main areas in which the HAES approach differs from pretty much every other “lifestyle modification” program out there is that it encourages body acceptance as opposed to weight loss or weight maintenance, supports intuitive eating rather than cognitively-imposed dietary restriction, and supports active embodiment as opposed to encouraging structured exercise.
I cannot begin to tell you how important these three components of the HAES approach have changed my life. I am slowly learning to accept my body, to eat intuitively and to enjoy movement. My life today is barely recognisable to the way it was when I started this blog less than a year ago. My first blog post was entitled “weight loss the hard way”. I think that shows just how far I have come.