Saturday, April 28, 2012

The Thesis - Executive Summary

So sorry about the lack of updates.  I have been working on my thesis.  I thought briefly about posting the whole thing on here.  But then I realized that I don’t want to inflict that on anyone. 

Here’s the executive summary.

1. People seem to think obesity is a big deal.  Two thirds of American adults are overweight or obese – everybody panic!

2. Obesity stigma is prejudice against overweight and obese people.  It’s a real thing in the world, especially the world of healthcare.  It turns out lots of doctors think obese people  are lazy, weak-willed, stupid, annoying, incompetent, non-compliant, and generally icky.

3.  People justify these beliefs by claiming that obesity is under personal control.  See, it isn’t like race, because I am not white on purpose.  But being fat is a choice.  So if fat people didn’t want to be discriminated against they could just stop being fat.  (Kind of like how poor people should just work harder and pull themselves up by their boot straps.) 

4. Nope, turns out that obesity is not a choice.  Turns out nothing else you thought you knew about obesity is true, either:

            Myth: Obesity is primarily caused by poor individual choices about diet and exercise.
Fact: Obesity is caused by a complex interaction of genetic, microbial, neuroendocrine, environmental, social, economic, psychological, and cultural factors – most of which are NOT under personal control.

            Myth: Obese and overweight people could lose weight if they actually tried.
Fact: Diet and exercise do not work.  Not only are 95% of weight loss attempts unsuccessful at producing long-term weight loss, evidence also indicates that dieting often actually leads to weight gain, increased stress, and disordered eating behavior.

Myth: Obesity is a serious medical problem.
Fact: The lowest mortality risk is actually associated with BMI values officially in the “overweight” range, especially for non-whites. Few studies of the association between BMI and health problems bother to control for exercise or dietary quality.  The truth is, you can be fit and fat.

5. Our society’s prejudice against fat people comes from our psychological need to protect ourselves from the possibility of bad things happening to us.  In our society, thin = beautiful, and therefore being fat is a bad outcome.  Rather than just feel sorry for fat people, we need to insulate ourselves against the threat they represent. We need to convince ourselves that the universe is a just place, that hard work pays off, that good things happen to good people and bad things happen to bad people.  Ergo, fat people must be bad. 

6. Obesity stigma is a problem because it is a prejudice just like sexism, racism, and homophobia and it has no place in a just society.  A full two thirds of the US adult population are victims of obesity stigma, so the effects are wide-spread.  These effects include psychological distress as well as more concrete discrimination in the areas of education, employment, housing, parental rights, and others.

7. Obesity stigma is a particular problem for doctors because it means we are violating the principles of beneficence and non-maleficence.  Our current treatment of obesity (nagging patients about dieting and exercising) does not work and is often actively harmful to patients’ overall well-being.  Fat patients find the experience of coming to the doctor to be so shaming (what with the nagging, lack of appropriate waiting room chairs, gowns, exam tables, and blood pressure cuffs, and mandatory weighing) that they avoid seeking care altogether.

8. For physicians and other healthcare providers, the solution lies in embracing the principles of Size Acceptance and practicing a medical model known as Health At Every Size (HAES).  HAES is a new approach to fat patients that emphasizes overall well-being rather than weight loss.  The core principles of HAES include, “accepting and respecting the diversity of body shapes and sizes; recognizing that health and well-being are multi-dimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects; promoting all aspects of health and well-being for people of all sizes; promoting eating in a manner which balances individual nutrition needs, hunger, satiety, appetite, and pleasure; and promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.”

9. Health At Every Size interventions have been proven to be effective in improving psychological markers of well-being, decreasing disordered eating behaviors, and improving cardiovascular markers of health such as cholesterol level and blood pressure.  Furthermore, no randomized controlled trial of HAES has shown weight gain to be an effect, and several such studies have pointed to HAES leading to modest weight loss. (Not that we care about the weight loss, but just in answer to all the critics who think intuitive eating will lead to weight ballooning out of control - it doesn't.)

10.  In addition to using HAES interventions with individual patients, physicians should also combat obesity stigma in their roles as practice managers and community health advocates. (For example, resisting public health messages that participate in fat-shaming in the name of advocating for personal responsibility.)

11.  In conclusion, obesity stigma is bad, doctors have been responsible for perpetuating it, and now it is our responsibility to fight it.

Whew.  That is all.


  1. This is brilliant and if you don't mind, I would like to print it out to take with me to new doctors who are most likely going to try to shame the fat pants off of me!

  2. Thanks! And feel free to take this to your doctor. If you want - I can send you the full version (which should be ready in a few short hours).

    A shorter and already published paper that makes a lot of these points can be found here: Weight Science: Evaluating the Evidence for a Paradigm Shift I totally recommend taking it to your doctor - and please let me know how it is received!

  3. Ok, but here is the thing. First the disclaimer: I am a linguist, not a medical Dr. I am overweight so this is not a thin person ranting at fat person thing. I have a long line of short tubbies above me on my Mum's size. But...

    you cannot deny that obesity is a bigGER problem in the US, Aust etc than in - say - I dunno, Siberia. And that we just happen to be those that eat HUGE servings and a load of crap. In the US (I've been a dozen times or so) I have so much trouble remembering to ask for small everything so I get something equal to large in Aust. I am not kidding. Some of those coffee or drink cups are buckets. Not cups.

    IF people are not drinking gallons of sugar etc AND they are still overweight, then sure, they can be healthy. I bushwalk, climb, canyon etc as do many friends who are overweight and fit. But if I'm drinking gallons of soft drink (you call soda) then my Dr should tell me to stop it. It isn't good for my health. Or my joints (which is where I'm having trouble).

    This is not to deny other issues. I read The Beauty Myth at Uni and Real Gorgeous by Kaz Cooke etc. I'm very aware of the role of the media to distort images etc. But being overweight DOES lead to an increase in some conditions AND we did not evolve joints etc to be that size.

    Feel free to rip all this apart. I know you know more than me!! And I ought, I guess, just read your thesis when it's done.

  4. Hahaha! Side. Not size. Could have been a typo. Probably a Freudian slip.

  5. Yay!

    I am overweight, technically obese. I work out hard 4-5 times a week. Eat mainly organic, healthy foods - no caffeine, no added salt or sugar, etc. Yes, occasionally I will splurge on ice cream or something of the like. And that is rare. Yet no weight loss.

    Medical Doctors for years have told me that I need to lose weight in order to eliminate my back pain, irregular periods, headaches, etc. Telling me that and leaving the room doesn't help me! Come to find out when a doctor actually took the time to listen to me and believe me, I have PCOS. Lots of doctors say that obesity causes PCOS. For me it is the opposite. The PCOS came first, and it makes it impossible for me to lose weight, I only continue to gain weight. I've found that is extremely common with women who have PCOS.

    I am one of those people who tries very hard to be healthy throughout my life, but the outside of my body doesn't show that effort. I have gotten many negative comments made to my face, and those made behind my back that I can hear. I am actually not extremely large (size 16/18), so I have no idea how people larger than me survive with all the comments and size-ism.

    Very interesting post!

  6. M: B passed this on to me. This. Is. Awesome. Thank you.

    p.s. I would read the whole thing. ;-)