Like Comparing Fat People and Oranges

I was reminded of the issues with research about health and weight recently by the fabulous and brilliant Tigress Osborn who said on Facebook “Fat IS associated with all the things she mentioned. Those conditions are often found alongside fat. So? Peanut butter is associated with grape jelly, too, but that doesn’t mean grape jelly comes from peanuts.” I talked about the correlation vs. causation issue in depth here.   Today I want to look at another error that happens in research about weight and health. 

When studies compare thin people and fat people, often reporters, healthcare professionals, well-meaning family and friends, not-at-all-well-meaning internet trolls, and sometimes even the researchers themselves act like it’s a simple comparison – that if, for example, fat people have higher rates of a health issue than thin people, then obviously the health issue must be caused by their fat.  It’s not even close to that simple though, when they compare fat people and thin people, they’re comparing a lot more than just body sizes:

They are comparing histories of dieting

People who diet are asked to eat less than their body needs in the hopes that the body will eat itself and become smaller. Almost every attempt succeeds in the short term, but fails in the long term with the person regaining as much or more weight than they lost.  Our current social constructs around body size suggest that everyone who fails to maintain weight loss (which, remember, is almost everyone) should go through that cycle again.  And again.  And again. Until we are either thin or dead (for most of us it will be the latter.)

And that doesn’t even get into the things that are recommended to fat people  that would be considered dangerous for thin people (a liquid diet, dangerous drugs, eating 500 calories a day and getting urine injections etc.) Many fat people have spent the majority of their lives on diets like this (and with the advent of the war on fat kids, wherein they’re starting in the womb and trying to get medicare to cover weight loss for the elderly, this is more true all the time.)

So they may not be studying the effects of being fat so much as they’re studying the effects of a lifetime of attempting to be thin through dieting.

They are comparing different levels of stigma

In US culture (and many others) fat people live in a world where we, and everyone we are unwilling combatants in a government-sponsored war.  Every single  person who we ever meet has been told repeatedly by the government, the media, and who knows how many others, that our bodies are bad, wrong, drains on society, proof that we are immoral, bad people etc. In the US the government is waging a war on everyone who is perceived to be fat, actually encouraging people to stereotype us, encouraging everyone from parents to pop stars to personal trainers to insist that they are stigmatizing and oppressing us for our own good.

We live in a world where we don’t know if the next person we meet – from family and friends, to our significant other’s family, coworkers, grocery store clerks, to strangers on the street and internet – will fat-shame us, treat us poorly because of our size, call us names,  throw eggs at us, try to pray our fat away, or send us hatemail and death threats.

We are the butt of jokes in stand-up comedy , companies use the idea that we should be embarrassed to be seen to sell products, we are used in memes as metaphors for greed, capitalism, laziness and more. People create web forums and web pages for the sole purpose of hating and making fun of us for how we look, including suggesting that we’re not human. Fitness forums have “fat hate days” where they make fun of fat people and send us hatemail. And because this bullying is based on our appearance, there’s no way to hide short of never leaving our homes (and even then it comes to us through our computers and our televisions) This is all day, every single day of our lives.

So they may not be studying the effects of being fat so much as they’re studying the effects of a lifetime of ceaseless bullying, shaming, stigma, being told that you should hate your body and that your body is bad, and the resulting oppression.

They are comparing different health care access and experience

Until Obamacare, insurance companies were allowed to (and did!) refuse to cover people based on BMI (a simple ratio of weight and height) as a “pre-existing condition”, so by virtue of being fat many of us (including me) were denied insurance coverage and therefore had very different access to medical care than those who had access to insurance. Even if they can afford it, fat people who go to the doctor can expect to get a lecture on our weight regardless of (and sometimes to the complete exclusion of) what we came in for.

In some cases fat people are given a “prescription”  to eat less and exercise more (often without being asked how much they currently eat or exercise), when a thinner person would have been given an evidence-based intervention specific to their health condition.  The biases of the doctors, nurses, technicians etc. against fat people may make the experience miserable, and cloud their ability to give good care. While doctors are perfectly willing to perform dangerous stomach amputation surgery, they will deny other surgical interventions based on weight.

The facility may not have equipment that accommodates us (beds, blood pressure cuffs, surgical instruments etc. – though they seem to have them right on hand when they are suggesting dangerous – and highly profitable – stomach amputation, that’s a subject for another blog), In addition to this meaning that there is some care we can’t get it can cause other complications as well.  Since doctor’s often don’t have properly-sized blood pressure cuffs, and since too-small cuffs can lead to artificially high readings, and since there is an assumption that fat people have high blood pressure, we have no idea how many fat people are on blood pressure medication (with all of its side effects) unnecessarily.

Doctor’s bigotry against fat patients can lead to those patients not being listened to or trusted as good witnesses to their own experiences. Finally, since doctors have a nasty tendency to diagnose fat people based on our body size, in studies that rely on self-reporting, fat people may be reporting health issues that they don’t actually have.

So they may not be studying the effects of being fat so much as they’re studying the effects of a lack of access to compassionate, competent, evidence-based healthcare.

Let’s be super clear that health is multi-dimensional, not entirely within our control, not an obligation, never a barometer of worthiness, or guaranteed under any circumstances.  This is simply about the fact that everyone should have access to the best possible information so that they can make decisions about their own bodies.  Researchers and healthcare professionals ignoring the very real limitations of their research to say that if Group A has a higher health risks than group B then the obvious solution is to try to make Group A look like Group B (also completely ignoring the fact that the research suggests that even if it would work, it isn’t possible) is not the best possible information, it’s not even in the ballpark.

Let’s look at a final example: Research found that men with certain baldness patterns have a much higher risk of heart disease.  Additional research found that the baldness and heart disease likely have the same root cause.  Thank goodness the weight loss people weren’t in charge of this or instead of the additional research we’d have a government-sponsored War on Baldness and a sixty billion dollar industry telling men that they have to  grow their hair back to be healthy and that if they don’t it’s their fault, accompanied by reporters whipping everyone into a frenzy with articles about how much bald men who get heart disease are costing society. Researchers and healthcare professional can do better, they should do better, and we can start demanding that they do better by asking questions of them, the journalists who report the studies, and the healthcare practitioners who use their research.

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