Final reflection

S E P T E M B E R 1 9 , 2 0 1 8

Everything You Know About

Obesity Is Wrong For decades, the medical community has ignored mountains of evidence

to wage a cruel and futile war on fat people, poisoning public perception

and ruining millions of lives.

It’s time for a new paradigm.

S T O R Y BY

Michael Hobbes

I M A G E S BY

Finlay MacKay

F rom the 16th century to the 19th, scurvy killed around 2

million sailors, more than warfare, shipwrecks and syphilis

combined. It was an ugly, smelly death, too, beginning with

rattling teeth and ending with a body so rotted out from the

inside that its victims could literally be startled to death by a

loud noise. Just as horrifying as the disease itself, though, is that for most of

those 300 years, medical experts knew how to prevent it and simply failed to.

In the 1600s, some sea captains distributed lemons, limes and oranges to

sailors, driven by the belief that a daily dose of citrus fruit would stave off

scurvy’s progress. The British Navy, wary of the cost of expanding the

treatment, turned to malt wort, a mashed and cooked byproduct of barley

which had the advantage of being cheaper but the disadvantage of doing

nothing whatsoever to cure scurvy. In 1747, a British doctor named James

Lind conducted an experiment where he gave one group of sailors citrus

slices and the others vinegar or seawater or cider. The results couldn’t have

been clearer. The crewmen who ate fruit improved so quickly that they were

able to help care for the others as they languished. Lind published his

findings, but died before anyone got around to implementing them nearly 50

years later.

This kind of myopia repeats throughout history. Seat belts were invented

long before the automobile but weren’t mandatory in cars until the 1960s.

The first confirmed death from asbestos exposure was recorded in 1906, but

the U.S. didn’t start banning the substance until 1973. Every discovery in

public health, no matter how significant, must compete with the traditions,

assumptions and financial incentives of the society implementing it.

Which brings us to one of the largest gaps between science and practice in

our own time. 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.

I have never written a story where so many of my sources cried during interviews, where they shook with anger describing their interactions with doctors and strangers and their own families.

About 40 years ago, Americans started getting much larger. According to the

Centers for Disease Control and Prevention, nearly 80 percent of

and about

one-third of

now meet the clinical definition of overweight or obese. More

Americans live with “extreme obesity“ than with breast cancer, Parkinson’s,

Alzheimer’s and HIV put together.

adults (http

s://www.cdc.gov/nchs/data/hestat/obesity_adult_15_16/obesity_adult_15_16.pdf)

children (https://www.cdc.gov/nchs/data/hestat/obesity_child_15_16/obesity

_child_15_16.pdf)

And the medical community’s primary response to this shift has been to

blame fat people for being fat. Obesity, we are told, is a personal failing that

strains our health care system, shrinks our GDP and saps our military

strength. It is also an excuse to bully fat people in one sentence and then

inform them in the next that you are doing it for their own good. That’s why

the fear of becoming fat, or staying that way, drives Americans to spend

more on dieting every year than we spend on video games or movies. Forty-

five percent of adults

they’re preoccupied with their weight some or all of the time—

an 11-point rise since 1990. Nearly half of 3- to 6- year old girls say they about being

fat.

say (https://news.gallup.com/poll/174089/nearly-half-remain-worri

ed-weight.aspx)

wo

rry (http://stars.library.ucf.edu/cgi/viewcontent.cgi?article=4747&context=etd)

The emotional costs are incalculable. I have never written a story where so

many of my sources cried during interviews, where they double- and triple-

checked that I would not reveal their names, where they shook with anger

describing their interactions with doctors and strangers and their own

families. One remembered kids singing “Baby Beluga” as she boarded the

school bus, another said she has tried diets so extreme she has passed out and

yet another described the elaborate measures he takes to keep his spouse

from seeing him naked in the light. A medical technician I’ll call Sam (he

asked me to change his name so his wife wouldn’t find out he spoke to me)

said that one glimpse of himself in a mirror can destroy his mood for days. “I

have this sense I’m fat and I shouldn’t be,” he says. “It feels like the worst kind

of weakness.”

My interest in this issue is slightly more than journalistic. Growing up, my

mother’s weight was the uncredited co-star of every family drama, the

obvious, unspoken reason why she never got out of the car when she picked

me up from school, why she disappeared from the family photo album for

years at a time, why she spent hours making meatloaf then sat beside us

eating a bowl of carrots. Last year, for the first time, we talked about her

weight in detail. When I asked if she was ever bullied, she recalled some guy

calling her a “fat slob” as she biked past him years ago. “But that was rare,” she

says. “The bigger way my weight affected my life was that I waited to do

things because I thought fat people couldn’t do them.” She got her master’s

degree at 38, her Ph.D. at 55. “I avoided so many activities where I thought

my weight would discredit me.”

But my mother’s story, like Sam’s, like everyone’s, didn’t have to turn out like

this. For 60 years, doctors and researchers have known two things that could

have improved, or even saved, millions of lives. The first is that diets do not

work. Not just paleo or Atkins or Weight Watchers or Goop, but all diets. Since 1959, research has shown that 95 to 98 percent of attempts to lose

weight fail and that two-thirds of dieters gain back more than they lost. The

Chances of a woman classified as obese achieving a “normal” weight:

0.8% SOURCE: AMERICAN JOURNAL OF PUBLIC HEALTH, 2015

reasons are biological and irreversible. As early

as 1969, research showed that losing just 3

percent of your body weight resulted in a 17

percent slowdown in your metabolism—a body-

wide starvation response that blasts you with

hunger hormones and drops your internal

temperature until you rise back to your highest

weight. Keeping weight off means fighting your

body’s energy-regulation system and battling

hunger all day, every day, for the rest of your

life.

The second big lesson the medical establishment has learned and rejected

over and over again is that weight and health are not perfect synonyms. Yes,

nearly every population-level study finds that fat people have worse

cardiovascular health than thin people. But individuals are not averages:

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

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.

Stud

ies (https://www.ncbi.nlm.nih.gov/pubmed/25040597/)

2016

study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4731253/)

The terrible irony is that for 60 years, we’ve approached the obesity epidemic

like a fad dieter: If we just try the exact same thing one more time, we'll get a different result. And so it’s time for a paradigm shift. We’re not going to

T his is Corissa Enneking at her lightest: She wakes up,

showers and smokes a cigarette to keep her appetite

down. She drives to her job at a furniture store, she

stands in four-inch heels all day, she eats a cup of yogurt

alone in her car on her lunch break. After work,

lightheaded, her feet throbbing, she counts out three Ritz crackers, eats them

at her kitchen counter and writes down the calories in her food journal.

Or not. Some days she comes home and goes straight to bed, exhausted and

dizzy from hunger, shivering in the Kansas heat. She rouses herself around

dinnertime and drinks some orange juice or eats half a granola bar.

Occasionally she’ll just sleep through the night, waking up the next day to

start all over again.

The last time she lived like this, a few years ago, her mother marched her to

the hospital. “My daughter is sick,” she told the doctor. “She's not eating.” He

looked Enneking up and down. Despite six months of starvation, she was still

wearing plus sizes, still couldn’t shop at J. Crew, still got unsolicited diet

advice from colleagues and customers.

Enneking told the doctor that she used to be larger, that she’d lost some

weight the same way she had lost it three or four times before—seeing how

far she could get through the day without eating, trading solids for liquids,

food for sleep. She was hungry all the time, but she was learning to like it.

When she did eat, she got panic attacks. Her boss was starting to notice her

erratic behavior.

become a skinnier country. But we still have a chance to become a healthier

one.

“Well, whatever you're doing now,” the doctor said, “it's working.” He urged

her to keep it up and assured her that once she got small enough, her body

would start to process food differently. She could add a few hundred calories

to her diet. Her period would come back. She would stay small, but without

as much effort.

“If you looked at anything other than my weight,” Enneking says now, “I had

an eating disorder. And my doctor was congratulating me.”

Ask almost any fat person about her interactions with the health care system

and you will hear a story, sometimes three, the same as Enneking’s: rolled

eyes, skeptical questions, treatments denied or delayed or revoked. Doctors

are supposed to be trusted authorities, a patient’s primary gateway to healing.

But for fat people, they are a source of unique and persistent trauma. No

matter what you go in for or how much you’re hurting, the first thing you

will be told is that it would all get better if you could just put down the

Cheetos.

Emily went to a gynecological surgeon to have an ovarian cyst removed. The physician pointed out her body fat on the MRI, then said, “Look at that skinny woman in there trying to get out.”

This phenomenon is not merely anecdotal. Doctors have

appointments with fat patients and

show

in the minutes they do have. Negative words—“noncompliant,”

shorter (https://link.sp

ringer.com/article/10.1007/s13679-013-0070-y)

less emotional rapport (https://onlinelibrary.wiley.com/doi/abs/10.1002/oby.2038

4)

“overindulgent,” “weak willed”—pop up in their medical histories with higher

frequency. In one ,

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

OB-GYNs in South Florida

and discovered that 14 percent had barred all new patients weighing more

than 200 pounds.

study (https://www.ncbi.nlm.nih.gov/pubmed/11477511)

polled (http://articles.sun-sentinel.com/2011-05-16/health/fl-hk

-no-obesity-doc-20110516_1_gyn-ob-gyn-obese-patients)

Some of these doctors are simply applying the same presumptions as the

society around them. An anesthesiologist on the West Coast tells me that as

soon as a larger patient goes under, the surgeons start trading “high school

insults” about her body over the operating table. Janice O’Keefe, a former

nurse in Boston, tells me a doctor once looked at her, paused, then asked,

“How could you do this to yourself?” Emily, a counselor in Eastern

Washington, went to a gynecological surgeon to have an ovarian cyst

removed. The physician pointed out her body fat on the MRI, then said,

“Look at that skinny woman in there trying to get out.”

“I was worried I had cancer,” Emily says, “and she was turning it into a

teachable moment about my weight.”

Other physicians sincerely believe that shaming fat people is the best way to

motivate them to lose weight. “It’s the last area of medicine where we

prescribe tough love,” says Mayo Clinic researcher Sean Phelan.

In a 2013 ,

bioethicist Daniel Callahan argued for more stigma against fat people. “People don’t realize that they are obese or if they do realize it, it’s not

journal article (https://onlinelibrary.wiley.com/doi/epdf/10.1002/hast.114)

enough to stir them to do anything about it,” he tells me. Shame helped him

kick his cigarette habit, he argues, so it should work for obesity too.

This belief is cartoonishly out of step with a generation of research into

obesity and human behavior. As one of the (many) stigma researchers who

responded to Callahan’s article pointed out, shaming smokers and drug users

with D.A.R.E.-style “just say no” messages may have actually increased substance abuse by making addicts less likely to bring up their habit with

their doctors and family members.

Plus, rather obviously, smoking is a behavior; being fat is not. Jody Dushay,

an endocrinologist and obesity specialist at Beth Israel Deaconess Medical

Center in Boston, says most of her patients have tried dozens of diets and

have lost and regained hundreds of pounds before they come to her. Telling

them to try again, but in harsher terms, only sets them up to fail and then

blame themselves.

89% of obese adults have been bullied by their romantic partners SOURCE: UNIVERSITY OF CONNECTICUT, 2017

Not all physicians set out to denigrate their fat

patients, of course; some of them do damage

because of subtler, more unconscious biases.

Most doctors, for example, are fit—“If you go to

an obesity conference, good luck trying to get a

treadmill at 5 a.m.,” Dushay says—and have

spent more than a decade of their lives in the

high-stakes, high-stress bubble of medical

schools. According to several

, thin doctors are more confident in their

recommendations, expect their patients to lose more weight and are more

likely to think dieting is easy. Sarah (not her real name), a tech CEO in New

England, once told her doctor that she was having trouble eating less

throughout the day. “Look at me,” her doctor said. “I had one egg for

breakfast and I feel fine.”

studies (https://ww

w.nature.com/articles/ijo201333.epdf)

Then there are the glaring cultural differences. Kenneth Resnicow, a

consultant who trains physicians to build rapport with their patients, says

white, wealthy, skinny doctors will often try to bond with their low-income

patients by telling them, “I know what it’s like not to have time to cook.”

Their patients, who might be single mothers with three kids and two jobs,

immediately think “No, you don’t,” and the relationship is irretrievably

soured.

When Joy Cox, an academic in New Jersey, was 16, she went to the hospital

with stomach pains. The doctor didn’t diagnose her dangerously inflamed

bile duct, but he did, out of nowhere, suggest that she’d get better if she

stopped eating so much fried chicken. “He managed to denigrate my fatness

and my blackness in the same sentence,” she says.

Many of the financial and administrative structures doctors work within help

reinforce this bad behavior. The problem starts in medical school, where,

according to a ,

students receive an average of just 19 hours of nutrition education over four

years of instruction—five hours fewer than they got in 2006. Then the

trouble compounds once doctors get into daily practice. Primary care

physicians only get 15 minutes for each appointment, barely enough time to

ask patients what they ate today, much less during all the years leading up to

it. And a more empathic approach to treatment simply doesn’t pay: While

procedures like blood tests and CT scans command reimbursement rates

from hundreds to thousands of dollars, doctors receive as little as $24 to

provide a session of diet and nutrition counseling.

2015 survey (https://www.hindawi.com/journals/jbe/2015/357627/)

Lesley Williams, a family medicine doctor in Phoenix, tells me she gets an

alert from her electronic health records software every time she’s about to see

a patient who is above the “overweight” threshold. The reason for this is that

physicians are often required, in writing, to prove to hospital administrators

and insurance providers that they have brought up their patient’s weight and

formulated a plan to bring it down—regardless of whether that patient came

in with arthritis or a broken arm or a bad sunburn. Failing to do that could

result in poor performance reviews, low ratings from insurance companies

or being denied reimbursement if they refer patients to specialized care.

Another issue, says Kimberly Gudzune, an obesity specialist at Johns

Hopkins, is that many doctors, no matter their specialty, think weight falls

under their authority. Gudzune often spends months working with patients

to set realistic goals—playing with their grandkids longer, going off a

cholesterol medication—only to have other doctors threaten it all. One of her

patients was making significant progress until she went to a cardiologist who

told her to lose 100 pounds. “All of a sudden she goes back to feeling like a

failure and we have to start over,” Gudzune says. “Or maybe she just never

comes back at all.”

60% of the calories Americans consume come from “ultra- processed foods” SOURCE: BRITISH MEDICAL JOURNAL, 2016

And so, working within a system that neither

trains nor encourages them to meaningfully

engage with their higher-weight patients,

doctors fall back on recommending fad diets

and delivering bland motivational platitudes.

Ron Kirk, an electrician in Boston, says that for

years, his doctor's first resort was to put him on

some diet he couldn't maintain for more than a

few weeks. “They told me lettuce was a ‘free’

food,” he says—and he’d find himself carving up

a head of romaine for dinner.

In a that recorded

461 interactions with doctors, only 13 percent of patients got any specific

plan for diet or exercise and only 5 percent got help arranging a follow-up

visit. “It can be stressful when [patients] start asking a lot of specific

questions” about diet and weight loss, one doctor

study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3367376/)

told (https://www.ncbi.nlm.nih.g

researchers in 2012. “I don’t feel like I have the

time to sit there and give them private counseling on basics. I say, ‘Here’s

some websites, look at this.’” A

found that

nearly twice as many higher-weight Americans have tried meal-replacement

diets—the kind most likely to fail—than have ever received counseling from a

dietician.

ov/pmc/articles/PMC3462265/)

2016 survey (http://www.norc.org/PDFs/ASMBS%20

Obesity/ASMBS%20NORC%20Obesity%20Poll_Brief%20B%20REV010917.pdf)

“It borders on medical malpractice,” says Andrew (not his real name), a

consultant and musician who has been large his whole life. A few years ago,

on a routine visit, Andrew’s doctor weighed him, announced that he was

“dangerously overweight” and told him to diet and exercise, offering no

further specifics. Should he go on a low-fat diet? Low-carb? Become a

vegetarian? Should he do Crossfit? Yoga? Should he buy a fucking

ThighMaster?

“She didn't even ask me what I was already doing for exercise,” he says. “At

the time, I was training for serious winter mountaineering trips, hiking every

weekend and going to the gym four times a week. Instead of a conversation, I

got a sound bite. It felt like shaming me was the entire purpose.”

All of this makes higher-weight patients more likely to avoid doctors. Three

separate studies have found that fat women are more likely to die from breast

and cervical cancers than non-fat women, a result partially attributed to their

reluctance to see doctors and get screenings. Erin Harrop, a researcher at the

University of Washington, studies higher-weight women with anorexia,

who, contrary to the size-zero stereotype of most media depictions, are twice

as likely to report vomiting, using laxatives and abusing diet pills. Thin

women, Harrop discovered, take around three years to get into treatment,

while her participants spent an average of 13 and a half years waiting for their disorders to be addressed.

I f Sonya ever forgets that she is fat, the world will remind her.

She has stopped taking the bus, she tells me, because she can

sense the aggravation of the passengers squeezing past her. Sarah,

the tech CEO, tenses up when anyone brings bagels to a work

meeting. If she reaches for one, are her employees thinking,

“There goes the fat boss”? If she doesn’t, are they silently congratulating her

for showing some restraint?

Emily says it’s the do-gooders who get to her, the women who stop her on

the street and tell her how brave she is for wearing a sleeveless dress on a 95-

degree day. Sam, the medical technician, avoids the subject of weight

altogether. “Men aren’t supposed to think about this stuff—and I think about

it constantly,” he admits. “So I never let myself talk about it. Which is weird

because it’s the most visible thing about me.”

Again and again I hear stories of how the pressure to be a “good fatty” in

public builds up and explodes. Jessica has four kids. Every week is a birthday

party or family reunion or swimming pool social, another opportunity to

stand around platters of spare ribs and dinner rolls with her fellow moms.

“Your conscious mind is busy the whole day with how many calories is in

everything, what you can eat and who’s watching,” she says. After a few

intrusive comments over the years—should you be eating that?—she has learned to be careful, to perform the role of the impeccable fat person. She

nibbles on cherry tomatoes, drinks tap water, stays on her feet, ignores the

dessert end of the buffet.

“A lot of my job is helping people heal from the trauma of interacting with

the medical system,” says Ginette Lenham, a counselor who specializes in

obesity. The rest of it, she says, is helping them heal from the trauma of

interacting with everyone else.

Then, as the gathering winds down, Jessica and the other parents divvy up

the leftovers. She wraps up burgers or pasta salad or birthday cake, drives her

children home and waits for the moment when they are finally in bed. Then,

when she’s alone, she eats all the leftovers by herself, in the dark.

“It’s always hidden,” she says. “I buy a package of ice cream, then eat it all.

Then I have to go to the store to buy it again. For a week my family thinks

there’s a thing of ice cream in the fridge—but it’s actually five different ones.”

Ratio of soda and candy ads seen by black children compared to white children:

2:1 SOURCE: UCONN RUDD CENTER FOR FOOD POLICY AND OBESITY, 2015

This is how fat-shaming works: It is visible and

invisible, public and private, hidden and

everywhere at the same time. Research

consistently finds that larger Americans

(especially larger women) earn lower

and are less likely

to be hired and promoted. In a

, 500 hiring

managers were given a photo of an overweight

female applicant. Twenty-one percent of them described her as

unprofessional despite having no other information about her. What’s

worse, only a few cities and one state (nice work, Michigan) officially

prohibit workplace discrimination on the basis of weight.

salaries (ht

tp://www.jeffreyhunger.com/uploads/3/4/4/8/34481134/

27._major_tomiyama___hunger.pdf)

2017 survey (http

s://moneyish.com/ish/only-15-of-hiring-managers-would-

consider-hiring-an-overweight-woman/)

Paradoxically, as the number of larger Americans has risen, the biases against

them have become more severe. More than 40 percent of Americans

classified as obese now say they experience stigma on a daily basis, a rate far

higher than any other minority group. And this does terrible things to their

bodies. According to a 2015

, fat people who feel discriminated against have shorter life

study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC46

36946/)

expectancies than fat people who don't. “These findings suggest the

possibility that the stigma associated with being overweight,” the study

concluded, “is more harmful than actually being overweight.”

And, in a cruel twist, one effect of weight bias is that it actually makes you eat

more. The stress hormone cortisol—the one evolution designed to kick in

when you’re being chased by a tiger or, it turns out, rejected for your looks—

increases appetite, reduces the will to exercise and even improves the taste of

food. Sam, echoing so many of the other people I spoke with, says that he

drove straight to Jack in the Box last year after someone yelled, “Eat less!” at

him across a parking lot.

There’s a grim caveman logic to our nastiness toward fat people. “We’re

attuned to bodies that look different,” says Janet Tomiyama, a stigma

researcher at UCLA. “In our evolutionary past, that might have meant

disease risk and been seen as a threat to your tribe.” These biological

breadcrumbs help explain why stigma begins so early. Kids as young as 3

their larger

classmates with words like “mean,” “stupid” and “lazy.”

desc

ribe (https://www.sciencedirect.com/science/article/pii/S0193397399800495)

And yet, despite weight being the number one reason children are bullied at

school, America’s institutions of public health continue to pursue policies

perfectly designed to inflame the cruelty. TV and billboard campaigns still

slogans like “Too much screen

time, too much kid” and “Being fat takes the fun out of being a kid.” Cat

Pausé, a researcher at Massey University in New Zealand, spent months

looking for a single public health campaign, worldwide, that attempted to

reduce stigma against fat people and came up empty. In an incendiary case of

good intentions gone bad, about a dozen states now send children home with

“BMI report cards,” an intervention unlikely to have any effect on their

weight but almost certain to increase bullying from the people closest to

them.

us

e (https://www.ncbi.nlm.nih.gov/pubmed/22964792)

This is not an abstract concern: Surveys of higher-weight adults find that

their worst experiences of discrimination come from their own families.

Erika, a health educator in Washington, can still recite the word her father

used to describe her: “husky.” Her grandfather preferred “stocky.” Her mother

never said anything about Erika’s body, but she didn't have to. She obsessed

over her own, calling herself “enormous” despite being two sizes smaller than

her daughter. By the time Erika was 11, she was sneaking into the woods

behind her house and vomiting into the creek whenever social occasions

made starving herself impossible.

And the abuse from loved ones continues well into adulthood. A

found that 89 percent of obese adults had been bullied by

their romantic partners. Emily, the counselor, says she spent her teens and

20s “sleeping with guys I wasn’t interested in because they wanted to sleep

with me.” In her head, a guy being into her was a rare and depletable resource

she couldn’t afford to waste: “I was desperate for men to give me attention.

Sex was a good way to do that.”

2017 survey

(https://opencommons.uconn.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=7694&c

ontext=dissertations)

Eventually, she ended up with someone abusive. He told her during sex that

her body was beautiful and then, in the daylight, that it was revolting.

“Whenever I tried to leave him, he would say, ‘Where are you gonna find

someone who will put up with your disgusting body?’” she remembers.

Emily finally managed to get away from him, but she is aware that her love

life will always be fraught. The guy she’s dating now is thin—“think Tony

Hawk,” she says—and she notices the looks they get when they hold hands in

public. “That never used to happen when I dated fat dudes,” she says. “Thin

men are not allowed to be attracted to fat women.”

The effects of weight bias get worse when they’re layered on top of other

types of discrimination. A

found that African-American women are more likely to

become depressed after internalizing weight stigma than white women.

Hispanic and black teenagers also have significantly higher rates of

. And, in a

remarkable finding, rich people of color have higher rates of cardiovascular disease than poor people of color—the opposite of what happens with white

people. One explanation is that navigating increasingly white spaces, and

increasingly higher stakes, exerts stress on racial minorities that, over time,

makes them more susceptible to heart problems.

2012 study (https://www.ncbi.nlm.nih.gov/pmc/articles/P

MC5670735/#R4)

bulimia (ht

tps://www.nationaleatingdisorders.org/people-color-and-eating-disorders)

But 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

, the words obese

participants used to classify other obese people included gluttonous, unclean

and sluggish.

2005

study (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3165020/)

Andrea, a retired nurse in Boston, has been on commercial diets since she

was 10 years old. She knows how hard it is to slim down, knows what

women larger than her are going through, but she still struggles not to pass

judgment when she sees them in public. “I think, ‘How did they let it

happen?’” she says. “It’s more like fear. Because if I let myself go, I’ll be that

big too.”

Her position is all-too understandable. As young as 9 or 10, I knew that

coming out of the closet is what gay people do, even if it took me another

decade to actually do it. Fat people, though, never get a moment of declaring

S ince 1980, the obesity rate has doubled in 73 countries and

increased in 113 others. And in all that time, no nation has

reduced its obesity rate. Not one.

The problem is that in America, like everywhere else, our

institutions of public health have become so obsessed with

body weight that they have overlooked what is really killing us: our food

supply. Diet is the cause of death

in the United States, responsible for more than five times the fatalities of gun

violence and car accidents combined. But it’s not how much we’re eating—

leading (http://europepmc.org/articles/pmc5408160)

their identity, of marking themselves as part of a distinct group. They still

live in a society that believes weight is temporary, that losing it is urgent and

achievable, that being comfortable in their bodies is merely “glorifying

obesity.” This limbo, this lie, is why it’s so hard for fat people to discover one

another or even themselves. “No one believes our It Gets Better story,” says

Tigress Osborn, the director of community outreach for the National

Association to Advance Fat Acceptance. “You can’t claim an identity if

everyone around you is saying it doesn’t or shouldn’t exist.”

Harrop, the eating disorders researcher, realized several years ago that her

university had clubs for trans students, immigrant students, Republican

students, but none for fat students. So she started one—and it has been a

resounding, unmitigated failure. Only a handful of fat people have ever

showed up; most of the time, thin folks sit around brainstorming about how

to be better allies.

I ask Harrop why she thinks the group has been such a bust. It’s simple, she

says: “Fat people grow up in the same fat-hating culture that non-fat people

do.”

Americans actually

fewer calories now than we did in 2003. It’s what we’re eating.

consume (https://www.nytimes.com/2015/07/25/upshot/americans-

are-finally-eating-less.html)

For more than a decade now, researchers have found that the quality of our

food affects disease risk independently of its effect on weight. Fructose, for

example, appears to

insulin sensitivity and liver function more than other sweeteners with the

same number of calories. People who eat nuts four times a week

12 percent lower diabetes incidence and a

13 percent lower mortality rate regardless of their weight. All of our

biological systems for regulating energy, hunger and satiety get thrown off by

eating foods that are high in sugar, low in fiber and injected with additives.

And which now, shockingly, make up 60 percent of the calories we eat.

damage (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC267387

8/)

have (https://

www.ncbi.nlm.nih.gov/pubmed/28049747)

Draining this poison from our trillion-dollar food system is not going to

happen quickly or easily. Every link in the chain, from factory farms to

school lunches, is dominated by a Mars or a Monsanto or a McDonald’s, each

working tirelessly to lower its costs and raise its profits. But that’s still no

reason to despair. There’s a lot we can do right now to improve fat people’s

lives—to shift our focus for the first time from weight to health and from

shame to support.

The place to start is at the doctor’s office. The central failure of the medical

system when it comes to obesity is that it treats every patient exactly the

same: If you’re fat, lose some weight. If you’re skinny, keep up the good work. Stephanie Sogg, a psychologist at the Mass General Weight Center, tells me she has clients who start eating compulsively after a sexual assault,

others who starve themselves all day before bingeing on the commute home

and others who eat 1,000 calories a day, work out five times a week and still

insist that they’re fat because they “have no willpower.”

Acknowledging the infinite complexity of each person’s relationship to food,

exercise and body image is at the center of her treatment, not a footnote to it.

“Eighty percent of my patients cry in the first appointment,” Sogg says. “For

something as emotional as weight, you have to listen for a long time before

you give any advice. Telling someone, 'Lay off the cheeseburgers' is never

going to work if you don't know what those cheeseburgers are doing for

them.”

4% of all agricultural subsidies go to fruits and vegetables SOURCE: ENVIRONMENTAL WORKING GROUP, 2014-16

The medical benefits of this approach—being

nicer to her patients than they are to

themselves, is how Sogg describes it—are

unimpeachable. In 2017, the

, the expert panel

that decides which treatments should be offered

for free under Obamacare, found that the

decisive factor in obesity care was not the diet patients went on, but how

much attention and support they received while they were on it. Participants

who got more than 12 sessions with a dietician saw significant reductions in

their rates of prediabetes and cardiovascular risk. Those who got less

personalized care showed almost no improvement at all.

U.S. Preventive Se

rvices Task Force (https://www.uspreventiveservicesta

skforce.org/Page/Document/RecommendationStatementFi

nal/obesity-in-adults-interventions1)

Still, despite the Task Force’s explicit recommendation of “intensive,

multicomponent behavioral counseling” for higher-weight patients, the vast

majority of insurance companies and state health care programs define this

term to mean just a session or two—exactly the superficial approach that

years of research says won’t work. “Health plans refuse to treat this as

anything other than a personal problem,” says Chris Gallagher, a policy

consultant at the Obesity Action Coalition.

The same scurvy-ish negligence shows up at every level of government.

From marketing rules to antitrust regulations to international trade

agreements, U.S. policy has created a food system that excels at producing

flour, sugar and oil but struggles to deliver nutrients at anywhere near the

same scale. The United States spends $1.5 billion on nutrition research every

year compared to around $60 billion on drug research. Just 4 percent of

agricultural subsidies go to fruits and vegetables. No wonder that the

healthiest foods can cost up to

more, calorie for calorie, than the

unhealthiest—or that the gap gets wider every year.

eight times (https://www.sciencedirect.com/science/ar

ticle/pii/S030691921000076X?via%253Dihub)

It’s the same with exercise. The cardiovascular risks of sedentary lifestyles,

suburban sprawl and long commutes are well-documented. But rather than

help mitigate these risks—and their disproportionate impact on the poor—

our institutions have exacerbated them. Only

of American children

walk or bike to school; once they arrive,

of them will take part in a daily gym class.

Among adults, the number of workers commuting more than 90 minutes

each way grew by more than 15 percent from 2005 to 2016, a predictable

outgrowth of America’s underinvestment in public transportation and over-

investment in freeways, parking and strip malls. For 40 years, as politicians

have told us to eat more vegetables and take the stairs instead of the elevator,

they have presided over a country where daily exercise has become a luxury

and eating well has become extortionate.

13 percent (http://guide.saferoutesin

fo.org/introduction/the_decline_of_walking_and_bicycling.cfm)

less than a third (https://www.cdc.gov/m

mwr/volumes/65/ss/ss6506a1.htm)

The good news is that the best ideas for reversing these trends have already

been tested. Many “failed” obesity interventions are, in fact, successful eat-

healthier-and-exercise-more interventions. A

of 44 international studies

found that school-based activity programs didn’t affect kids’ weight, but

improved their athletic ability, tripled the amount of time they spent

review (https://www.cornwallhealth

yschools.org/documents/Cochrane_Review_June_2013.pdf)

exercising and reduced their daily TV consumption by up to an hour.

showed that two

years of getting kids to exercise and eat better didn’t noticeably affect their

size but did improve their math scores—an effect that was greater for black

kids than white kids.

Anothe

r survey (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2836343/)

You see this in so much of the research: The most effective health

interventions aren't actually health interventions—they are policies that ease

the hardship of poverty and free up time for movement and play and

parenting. Developing countries with higher wages for women have lower

obesity rates, and lives are transformed when healthy food is made cheaper.

A pilot in

Massachusetts that gave food stamp recipients an extra 30 cents for every $1

they spent on healthy food increased fruit and vegetable consumption by 26

percent. Policies like this are unlikely to affect our weight. They are almost

certain, however, to significantly improve our health.

program (https://mafoodsystem.org/media/resources/pdfs/PilotFinalReport.pdf)

Which brings us to the most hard-wired problem of all: 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

, 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

with fifth- and sixth-graders actually increased their intention of bullying their fat classmates. Celebrity representation, meanwhile, can result

in what Corrigan calls the “Thurgood Marshall effect”: Instead of updating

our stereotypes (maybe fat people aren’t so bad), we just see prominent minorities as isolated exceptions to them (well, he’s not like those other fat people).

study (http://citeseerx.ist.psu.edu/viewdoc/

download?doi=10.1.1.175.4474&rep=rep1&type=pdf)

similar approach (https://www.ncbi.nlm.nih.gov/pubme

d/10780140)

What does work, Corrigan says, is for fat people to make it clear to everyone

they interact with that their size is nothing to apologize for. “When you pity

someone, you think they’re less effective, less competent, more hurt,” he says.

“You don’t see them as capable. The only way to get rid of stigma is from

power.”

This has always been the great hope of the fat-acceptance movement. (“We’re

here, we’re spheres, get used to it” was one of the slogans in the 1990s.) But

this radical message has long since been co-opted by clothing brands, diet

companies and soap corporations. Weight Watchers has

as a “lifestyle program,” but still promises that its members can shrink their

way to happiness. Mainstream apparel companies market themselves as

“body positive” but

clothes that fit the plus-size models on their

own billboards. Social media, too, has provided a platform for positive

representations of fat people and formed communities that make it easier to

find each other. But it has also contributed to an anodyne, narrow, Dr. Phil-

approved form of progress that celebrates the female entrepreneur who sells

“fatkinis” on Instagram, while ignoring the woman who (true story)

from her management position after

reportedly gaining 100 pounds over three years.

rebranded (https://ww

w.fastcompany.com/40500280/how-weight-watchers-transformed-itself-into-a-lifestyle-brand)

refuse to make (https://www.racked.com/2018/6/5/17236466/size-

appropriation-brands-clothes-plus-size)

gets fire

d (https://www.detroitnews.com/story/news/local/oakland-county/2015/10/20/woman-sues-

coach-claiming-fired-fat/74279642/)

“Fat activism isn’t about making people feel better about themselves,” Pausé

says. “It’s about not being denied your civil rights and not dying because a

doctor misdiagnoses you.”

And so, in a world that refuses to change, it is still up to every fat person,

alone, to decide how to endure. Emily, the counselor in Eastern Washington,

says she made a choice about three years ago to assert herself. The first time

she asked for a table instead of a booth at a restaurant, she says, she was

sweating, flushed, her chest heaving. It felt like saying the words—“I can’t

fit”—would dry up in her mouth as she said them.

But now, she says, “It’s just something I do.” Last month, she was at a

conference and asked one of the other participants if he would trade chairs

because his didn’t have arms. Like most of these requests, it was no big deal.

“A tall person wouldn’t feel weird asking that, so why should I?” she says. Her

skinny friends have started to inquire about the seating at restaurants before

Emily even gets the chance.

Hearing about Emily’s progress reminds me of a conversation I had with

Ginette Lenham, the diet counselor. Her patients, she says, often live in the

past or the future with their weight. They tell her they are waiting until they

are smaller to go back to school or apply for a new job. They beg her to

return them to their high school or wedding or first triathlon weight, the one

that will bring back their former life.

And then Lenham must explain that these dreams are a trap. Because there is

no magical cure. There is no time machine. There is only the revolutionary

act of being fat and happy in a world that tells you that’s impossible.

“We all have to do our best with the body that we have,” she says. “And leave

everyone else’s alone.” 

Correction: A previous version of this story inaccurately calculated the chance a woman classified as obese could achieve a “normal” weight. It is 0.8

percent, not 0.008 percent.

CREDITS

STORY - MICHAEL HOBBES

Michael is a regular contributor to Highline and a senior enterprise reporter for HuffPost. He is also the co-host of You're Wrong About, a weekly podcast.

PHOTOGRAPHY - FINLAY MACKAY

Finlay is a photographer and film director based in New York City. His work has appeared in The New York Times, Time and the National Portrait Gallery.

CREATIVE DIRECTION & DESIGN - DONICA IDA

Donica is the creative director of Highline.

ADDITIONAL ART DIRECTION & DESIGN - KATE LARUE

Kate is a creative director and journalist who lives in Brooklyn.

RESEARCH - MATT GILES

Matt is a freelance writer and the head of research and fact-checking at Longreads.

DEVELOPMENT & DESIGN - GLADEYE

Gladeye is a digital innovations agency in New Zealand and New York.