Is being fat bad for your health? Obesity sceptics disagree

Obesity Campaign Poster

Obesity Campaign Poster (Photo credit: Pressbound)

For some years now,  obesity sceptics have argued against the mainstream medical and public health perspective on obesity. Writers such as Paul Campos (2004), Michael Gard and Jan Wright (Gard and Wright, 2005; Gard, 2011)  have published closely argued critiques of the obesity science literature. They persuasively identify the many inaccuracies, distortions, misleading assumptions and generalisations made in scientific and epidemiological research which have contributed to the idea that obesity is at ‘crisis’ or ‘epidemic’ levels and that being over the arbitrarily defined ‘normal’ BMI automatically damages people’s health.

Some specific points obesity sceptics make are as follows:

  • It is not the case that there are far greater numbers of fat people now compared to several decades ago. While there has been a modest increase in average weight, this does not represent an ‘epidemic of obesity’.
  • Life expectancy in western countries has risen, not fallen, despite alleged growing rates of obesity and the supposed life-threatening health conditions caused by obesity.
  • There is no statistical evidence that being fat necessarily equates to a greater risk of ill health or disease. Statistics show that only those people at the extreme end of the weight spectrum (the ‘morbidly obese’ in medical terminology) demonstrate negative health effects from their weight. The data show that higher body weight may even be protective of health in older people.
  • The epidemiological literature has been unable to demonstrate that significant weight loss improves fat people’s health status. Indeed continual attempts by fat people to lose weight can actually be negative to their health status if it involves extreme diets, being caught in a cycle of losing and gaining weight or poor dietary habits.
  • Fatness is often a symptom rather than the cause of ill health and disease.
  • There is no consensus from the scientific literature that people in contemporary western societies are less active now than in previous eras: indeed many people, particularly those from the middle-class, are highly physically active.
  • No clear association has been found between activity levels and childhood overweight and obesity, or between children’s television watching habits and their body weight.
  • Nor have studies conclusively demonstrated that relative levels of physical activity influence health status. Medical research has not been able to show how much exercise should be undertaken and how often to achieve and maintain good health and which diseases are affected or prevented by taking regular exercise.
  • It is also very difficult to demonstrate scientifically the relative influence of genes in body weight.

In all these areas there are many contradictory and conflicting findings from research studies, making it difficult to anyone to make confident statements about these issues. As these obesity sceptics point out, many of the generalisations made by obesity scientists and public health experts simply disregard the lack of consistent, clear or conclusive evidence for such statements as ‘obesity is caused by lack of exercise and eating too much’ and continue to reiterate these assertions.

What obesity sceptics present, in essence, is a detailed critique of the ways in which political agendas and pre-existing assumptions shape the reporting and interpretation of medical and epidemiological data relating to body mass. Quite apart of its relevance to debate about whether the obesity epidemic exists and how serious it is, such an analysis is valuable in drawing attention to the work practices and knowledge claims of medical and public health researchers.

The assertions and critiques of obesity sceptics have failed to make an impact on mainstream obesity science, government health policy and anti-obesity public health efforts. Journal articles concerning the dangers of obesity continue to appear in medical and public health journals with monotonous frequency. Alarmist predictions continue to receive attention in the mass media. Governments in western countries have also continued to invest large sums to fund health promotion campaigns seeking to counter obesity. For example, the American ‘Let’s Move’ campaign, directed at controlling childhood obesity, was launched by First Lady Michelle Obama in early 2010, while on the same day President Obama created a Taskforce on Childhood Obesity. The Australian ‘Swap It, Don’t Swap It’ anti-obesity campaign commenced in early 2011. It would seem that there are powerful political and career investments in continuing to ignore the arguments of the obesity sceptics.

References

Campos, P. (2004) The Obesity Myth. New York: Gotham Books.

Gard, M. and Wright, J. (2005) The Obesity Epidemic. London: Routledge.

Gard, M. (2011) The End of the Obesity Epidemic. London: Routledge.

27 thoughts on “Is being fat bad for your health? Obesity sceptics disagree

  1. I write based upon my experience as an obesity researcher, and more specially as a paediatrician at The Children’s Hospital at Westmead, in western Sydney, where I work with severely obese children, young people and their families.

    The reason why the arguments of obesity skeptics are ignored is because their arguments lack substance and logic. There is an overwhelming body of evidence showing that obesity and obesity-related complications are, indeed, major health problems in most westernised and rapidly westernising countries.

    To address some of the points made:

    • It is not the case that there are far greater numbers of fat people now compared to several decades ago. While there has been a modest increase in average weight, this does not represent an ‘epidemic of obesity’.
    RESPONSE:
    Many epidemiological studies show that both average BMI, as well as the percentage of people who are classified as being overweight or obese, have increased in the past few decades in many countries. This is presented or reviewed in many studies. I highlight just a few:
    o Allman-Farinelli MA, Chey T, Bauman AE, Gill T, James WPT. Age, period and birth cohort effects on prevalence of overweight and obesity in Australian adults from 1990 to 2000. Eur J Clin Nutr 2008; 898-907.
    o Garnett SP, Baur LA, Cowell CT. The prevalence of increased central adiposity in Australian school children 1985 to 2007. Obesity Reviews 2011; 12:887-896.
    o Finucane MM, Stevens GA, Cowan NJ et al. National, regional and global trends in body-mass index since 1980: systematic analysis of health examinations surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011; 377:557-567.

    And simple observation of people in community settings – schools, shopping malls and so on – reinforce the consistent message of these studies. Many more people are overweight or obese now than they were three decades ago.

    • Life expectancy in western countries has risen, not fallen, despite alleged growing rates of obesity and the supposed life-threatening health conditions caused by obesity.
    RESPONSE:
    Indeed, life expectancy has increased in many westernised countries, including Australia. The biggest impact on life expectancy has been reduced infant mortality. This, combined with improvements in the prevention and management of a range of health problems, such as a welcome decrease in tobacco smoking, and the improved management of many non-communicable diseases, including heart disease and diabetes, has meant people are not dying as early as in the past.

    However, for those people who are obese, then life expectancy is decreased in comparison with people in a more healthy weight range. This is shown clearly in many epidemiological studies. One very rigorous study I would highlight is a collaborative analysis undertaken of baseline BMI versus mortality in 57 prospective studies with almost 900,000 participants, and published in the Lancet in 2009 (Prospective Studies Collaboration. Whitlock G, Lewington S, Sherliker P et al. Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373:1083-96). I quote from the abstract: “At 30-35 kg/m2, median survival is reduced by 2-4 years; at 40-45 kg/m2, it is reduced by 8-10 years (which is comparable with the effects of smoking).”

    • There is no statistical evidence that being fat necessarily equates to a greater risk of ill health or disease. Statistics show that only those people at the extreme end of the weight spectrum (the ‘morbidly obese’ in medical terminology) demonstrate negative health effects from their weight. The data show that higher body weight may even be protective of health in older people.
    RESPONSE:
    Again, this assertion is refuted in numerous studies, including the previously mentioned article by Whitlock and colleagues. To further quote from their article: “The progressive excess mortality above… (the apparent optimum of about 22.5-25 kg/m2)… is due mainly to vascular disease and is probably largely causal”.

    Obesity is also directly linked to the presence of a range of other health problems including type 2 diabetes, obstructive sleep apnoea, infertility, osteoarthritis and several cancers. These and other ill-health consequences are not restricted to those at the upper end of the weight spectrum, but the risk rises as weight increases. This has been documented in many independent studies and are, for example, summarised in the following:
    o World Cancer Research Fund and American Institute for Cancer Research Food, nutrition, physical activity, and the prevention of cancer: a global perspective, 2007. American Institute for Cancer Research, Washington, DC (2007).
    o M Ezzati, A Lopez, AD Rodgers, CJL Murray (Eds.), Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors, World Health Organization, Geneva (2004).

    • The epidemiological literature has been unable to demonstrate that significant weight loss improves fat people’s health status. Indeed continual attempts by fat people to lose weight can actually be negative to their health status if it involves extreme diets, being caught in a cycle of losing and gaining weight or poor dietary habits.
    RESPONSE:
    Again, there are several studies showing that weight loss leads to improvements in a range of health outcomes for obese people. One example is the long-term Swedish Obese Subjects (SOS) Study, in which people who had received bariatric surgery or medical treatment for their severe obesity were followed up long-term for 10 years. The surgery group had improvements in quality of life and reductions in type 2 diabetes, a range of cardiovascular risk factors, some cancers and gender-, age- and risk factor-adjusted mortality rate. (Sjöstrom L. Bariatric surgery and reduction in morbidity and mortality: experiences from the SOS study. Int J Obesity 2008; 32 Suppl 7:S93-97).

    • Fatness is often a symptom rather than the cause of ill health and disease.
    RESPONSE:
    Obesity certainly can be secondary to a range of health problems, including the use of specific medications (eg corticosteroids, antipsychotics, some anti-epileptics). In those situations, obesity needs to be carefully managed, as well as the underlying health problem. However, obesity is much more commonly a primary problem, or risk factor, which in turn contributes to the development of other health concerns, such as type 2 diabetes, heart disease, obstructive sleep apnoea, fatty liver disease and osteoarthritis.

    • There is no consensus from the scientific literature that people in contemporary western societies are less active now than in previous eras: indeed many people, particularly those from the middle-class, are highly physically active.
    RESPONSE:
    Whilst it may be true that participation in sport and organised exercise is as high today in westernised communities as in previous decades, the vast bulk of our energy expenditure in the past has not come from leisure time activity but rather from occupational and incidental activity. There is clear evidence of major drops in occupational activity, and energy expenditure through active transport (walking, cycling for transport) has decreased. However, there have also been dramatic changes in dietary intake, in sedentary behaviours (a separate phenomenon from physical activity) and sleep quality and duration over the past few decades, all of which influence the development of obesity.

    • No clear association has been found between activity levels and childhood overweight and obesity, or between children’s television watching habits and their body weight.
    RESPONSE:
    There is a wealth of data showing a link between sedentary behaviours such as TV viewing and the prevalence of obesity in children and young people, both in cross-sectional as well as longitudinal studies. Two indicative articles:
    o Garnett SP, Cowell CT, Baur LA et al. Increasing central adiposity: the Nepean longitudinal study of young people aged 7-8 to 12-13 years. Int J Obesity 2005; 29: 1353-1360.
    o Kuhl ES, Clifford LM, Stark LJ. Obesity in preschoolers: behavioural correlates and directions for treatment. Obesity 2012; 20:3-29.

    • Nor have studies conclusively demonstrated that relative levels of physical activity influence health status. Medical research has not been able to show how much exercise should be undertaken and how often to achieve and maintain good health and which diseases are affected or prevented by taking regular exercise.
    RESPONSE:
    Again, the important role of physical activity to health and well-being is demonstrated in numerous studies over many years, and, is, I am sure, well known to all of us as individuals. This includes a reduced risk of premature mortality and reduced comorbidities from heart disease, hypertension, colon cancer and diabetes, as well as a reduction in depression and anxiety, improved management of back pain and arthritis and reduced falls in elderly.

    • It is also very difficult to demonstrate scientifically the relative influence of genes in body weight.
    RESPONSE:
    There are many scientifically rigorous twin, adoption and family studies showing the major genetic contribution to the population variance in various measures of body fatness (including BMI, waist circumference, percentage body fat). This is one of the reasons that overweight tends to run in families (shared environmental factors are also important). Some key papers include those by Claude Bouchard and colleagues.

    I am aware that in responding as I have done, I may seem to be one of those people who have a “career investment” in “continuing to ignore the arguments of the obesity sceptics”. However, the data in support of the health and economic burden of obesity are compelling.

    But perhaps what might be the most convincing argument I could raise, is to encourage the obesity skeptics among you to visit Westfields at Parramatta or Penrith, or the entrance foyers of Westmead Hospital or The Children’s Hospital at Westmead. Just to stand and watch the passing parade of people will tell you a great deal about the impact of obesity on our community.

  2. Thank you for your detailed response, Louise. I’m just wondering, have you read the books to which I refer in the post? I was only able to give a brief summary of their arguments, but of course they provide much more detailed analysis to support their contentions in the books. And what is your view on the efficacy of the BMI in measuring obesity, given that this has come in for quite some criticism? Also, how many of your comments above relate specifically to the health risks of severe (morbid) obesity as compared with less extreme obesity or overweight as classified by the BMI?

  3. Dear Deborah

    I certainly have read some of the articles by Paul Campos and colleagues, although not the books.

    In 2006 there was an article by Campos et al entitled “The epidemiology of overweight and obesity: public health crisis or moral panic?” (Int J Epidemiol, 2006; 35:55-60) which I read at the time. Interestingly, there was a response article in the same issue of the journal, by Kim and Popkin entitled “Understanding the epidemiology of overweight and obesity—a real global public health concern” (Int J Epidemiol 2006; 35:60-67). The comments that Kim & Popkin made at the time still make much sense. But there are now 6 more years of strong epidemiological data to support some of their comments, including, for example, the 2009 Lancet article by Whitlock et al that I cited above.

    1) BMI and other measures of body fatness and fat distribution
    You ask about the usefulness of BMI as a measure of obesity. BMI is a reasonable measure of body fatness and is useful as both an epidemiological and a clinical screening tool. In fact, in the early and mid 1990s I was involved in several of the studies first looking at the usefulness of BMI in assessing body fatness in children and adolescents.

    Of course BMI is not so useful in assessing (the very small percentage of) small, muscular individuals, but in general it is incredibly useful – it’s cheap, non-invasive, and has good sensitivity and specificity as a screening tool. Again, there are numerous papers highlighting this, including several from me and my colleagues.

    In clinical practice we would of course supplement measurement of BMI with other forms of clinical assessment (eg history, family history, assessment of complications, measurement of fat distribution etc). However, it is impressive how robust BMI remains as the first line of assessment.

    There remains debate about the exact cut-point to denote healthy versus less healthy BMI – especially when considering ethnic variations. For example, health risks start at lower BMIs (eg less than 25 kg/m2) for people from Indian sub-continent of Aboriginal ethnic backgrounds than, say, those from Anglo-Northern European backgrounds. And they start at somewhat higher BMIs for people from Pacific and Maori background.

    2) Health risks of overweight and milder forms of obesity
    The health risks of increasing body fatness start with overweight and not just obesity ie they aren’t just at the severe end of obesity. Again, some of the articles I cited above highlight this. There’s a continuum – health risks increase as BMI increases. It’s also a U-shaped (or more realistically, a J-shaped) distribution – health risks also increase as BMI drops below an optimal range (generally thought to be 20-25 kg/m2).

    The 2004 NSW Schools Physical Activity and Nutrition Survey, which included a biomarker sub-study in 15 year olds, shows that even overweight (not obese) 15 year olds have a higher prevalence of abnormal cardio-metabolic risk markers than their more healthy weight peers. There are many other studies in the paediatric and adolescent age group showing that disease risk markers accumulate as BMI increases.

    3) “Epidemic”
    The CDC definition of an epidemic is: “The occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time.” It’s this definition that many epidemiologists and public health researchers are using when they discuss the “obesity epidemic”. I know that others are anxious about that particular terminology, but it seems very reasonable to me.

    Final Comments:
    Even if I were unfamiliar with the epidemiological data on obesity, my work as a clinician working in western Sydney would leave me in no doubt as to the major impact of obesity on individuals, families and communities. The health consequences of obesity are very real, and Australian health services are not coping with it.

    The challenge is not whether obesity is a problem or not, but how this complex, “wicked” problem of obesity can be best be tackled. I think that’s where the academic focus should lie.

  4. This was a very interesting read, it is always good to see a different point of view. However, as I see it, the arguments in the article look a lot like the arguments climate change skeptics make. ‘There is no consensus in this regard’, when in fact, there actually is – if there are skeptics outside medical research saying that they do not agree, that might look like there is no consensus to someone who has never read any article on the topic that appeared in a peer-reviewed journal, but not to those who are regular readers or writers of those. ‘There is no clear association between these two phenomena’, when the correlation is there for those who are not trying to unsee things. I am sorry if this sounds condescending, it’s just that the argument structure alone makes me skeptical.
    I do agree that BMI alone is not the best approach to assess someone’s physical health, but there are other markers that might also show a difference between people of normal and high BMI (in a population level), like blood pressure, blood triglyceride/cholesterol/sugar levels, blood insulin level or even oxygen saturation. What is your opinion on those, would you call them useless? I’m honestly curious.

    • Thank you for your comment. My post was summarising the main arguments of some very detailed arguments put forward by some of the obesity sceptics who themselves have gone through the medical and epidemiological research in much detail. I myself have not examined this literature in as much detail as they have, but I would urge those interested in following up the debate to go directly to the books to which I refer above so as to see what evidence these writers are drawing upon in developing their critique.

      What I do know is that there is a dissenting viewpoint, that this has been published in respected journals such as the International Journal of Epidemiology and that it should be acknowledged and engaged with. It is becoming more and more apparent that the science of body weight is extremely complex and that simplistic statements about diet (eat less) and exercise (do more) can serve to shame people who are deemed obese or engage them in a constant cycle of losing and regaining weight which is itself damaging of health. So too, statements about ‘obesity’ made in the public arena often conflate the various body weights which medically fall into this range, from mildly to severely overweight.

      In my own research as a sociologist I am interested in looking at the different viewpoints put forward on the ‘obesity epidemic’ and the knowledge claims used to represent these viewpoints. I am also interested in the ways in which the fat body is stigmatised, both as a result of obesity discourse but also as part of a longstanding cultural disdain for what is viewed as unregulated people who lack self-discipline. I have just completed a book on this subject (‘Fat’, to be published by Routledge).

  5. I will definitely check these books out. Again, the fact that none of these authors seem to have a degree in the medical field makes me skeptical, but I am curious about what kind of sources they used and what their arguments or counter-arguments are.

    I agree with you that oversimplifying does more harm than good, and this is the exact cause why I found the statements in this article debatable. It might be the product of trying to summarize a book in a few words, Claiming that there is no statistical data or decisive evidence on something is definitely oversimplifying. There is data that too much exercise is risky, or that losing weight in a short period is harmful; but there is also evidence that losing weight within a longer period with a balanced diet is beneficial, or that regular aerobic exercising is protective for the cardiovascular system. It is a fact that certain health conditions can cause weight gain or will make losing weight extremely difficult; but there is also an overwhelming amount of studies that indicate obesity as the main culprit behind diseases that are regrettably common,

    I also agree that fat-shaming leads nowhere; however, saying that there is no way obesity can cause harm does not seem more helpful to me.

    Please do answer the latter part of my previous comment, that is also an important question to me.

    (I am incredibly sorry if this is posted twice!)

    • Hi Emese

      As I said above, I did not myself go through the medical and epidemiological literature in detail, so I do not have a definite opinion on your question about disease and serological and other markers and how these are related to body weight. My own research focus is on different aspects of obesity: the sociocultural dimensions.

      But I am aware that there are debates around blood cholesterol levels, for example, concerning whether or not high levels necessarily result in disease, and that demonstrating elevated levels of a marker is a different issue from then presuming that a disease state will eventuate.

  6. Louise, you sound like a concerned professional anxious to help an ailing population. Have you read or heard about Health at Every Size (HAES), which supports the idea that healthy habits lead to healthier bodies, regardless of size? As you know, and express above in referring to the quandary as to these issues can be tackled, 95% of diets fail. As a result, HAES proponents–including thousands in the fields of medicine and nutrition–believe that focusing on increasing healthy habits is a more practical way to deal with so-called obesity-related diseases than trying to win the losing battle of food restriction and weight loss (both of which are shown to result, in the long term, in further weight gain, emotional distress, and abandonment of self-care.)

    Here is some supporting research on HAES concepts:

    1) Weight Science: Evaluating the Evidence for a Paradigm Shift:
    http://www.nutritionj.com/content/10/1/9
    Linda Bacon1* and Lucy Aphramor2,3
    Nutrition Journal 2011, 10:9 doi:10.1186/1475-2891-10-9
    1University of California, Davis, and City College of San Francisco, Box S-80, City College of San Francisco, 50 Phelan Avenue, San Francisco, CA 94112, USA
    2Coventry University, Applied Research Centre in Health and Lifestyle Interventions, Priory Street, Coventry, CV1 1FB, UK
    3University Hospitals Coventry and Warwickshire NHS Trust, Cardiac Rehab, Cardiology Suite, 1st Floor, East Wing, Walsgrave Hospital, Clifford Bridge Road, Coventry CV2 2DX, UK

    2) A study of 11,761 people: http://www.jabfm.org/content/25/1/9.abstract?etoc
    Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals
    Eric M. Matheson, MS, MD, Dana E. King, MS, MD and Charles J. Everett, PhD
    From the Department of Family Medicine, Medical University of South Carolina, Charleston.
    Corresponding author: Eric M. Matheson, Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425 (E-mail: Matheson@musc.edu).

    3) A study of 25,714 people: http://www.ncbi.nlm.nih.gov/pubmed/10546694
    JAMA. 1999 Oct 27;282(16):1547-53.
    Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men.
    Wei M, Kampert JB, Barlow CE, Nichaman MZ, Gibbons LW, Paffenbarger RS Jr, Blair SN.
    The Cooper Institute for Aerobics Research*, Dallas, Tex 75230, USA.
    The Cooper Institute Research on fitness and weight is based on the Cooper Institute Longitudinal Study http://www.cooperinstitute.org/ccls which is a database that has more than 250,000 records from nearly 100,000 people
    totaling more than 1,800,000 person-years of observation.

    • Ninafel, thanks for bringing up the Health at Every Size perspective. This is certainly a position that Campos and his colleagues place a great deal of emphasis on: the importance of physical fitness over body weight as a marker of and contributor to good health.

    • I share your passion and concerns about the stigmatisation that can occur towards people affected by obesity. And I am very familiar with the Health At Every Size concepts.

      Of course, good clinical practice should ALWAYS involve maximising management of any health complications e.g. treating obstructive sleep apnoea or type 2 diabetes. And we should all recognise the many psychological and physical health benefits – independent of whether weight loss is achieved or not – of individuals having more physically active lifestyles, with less sedentary behaviours, improved sleep quality & duration, and a diet lower in sugar, salt and saturated fats, and higher in fibre and vegetables.

      BUT…
      However, I’m sorry, but we just can’t escape the fact that excess weight itself does cause health problems. For example, osteoarthriitis in adults, a range of significant orthopaedic problems in childhood (e.g. slipped femoral epiphyses [hip], tibia vara [knees]), and obstructive sleep apnoea in both age groups, are largely mechanical problems caused by excess weight. The hip and knee problems result from an increased mechanical loading on various joints, and the obstructive sleep apnoea from excess fatty tissues in the neck and oropharynx. These problems are much more common now than they were two decades ago, and they are all much better managed when weight loss occurs.

      And, as commented previously, obesity-associated complications, such as type 2 diabetes and fatty liver disease, are also much more common now, basically as a consequence of the increased prevalence of obesity. And, again, the reality is that management of both diseases – and many others linked to obesity – is vastly improved if weight loss occurs.

      WEIGHT LOSS IS HARD
      Too right! It’s one of the reasons that I’d really like to see far more focus on preventing the problem of obesity, by addressing the upstream drivers of the problem.

      However, in an area with which I am very familiar – management of child and adolescent obesity – there are many studies, and now systematic reviews, showing that good quality treatment programs can lead to improved weight status AND improvements in quality of life, self-esteem, cardiovascular risk markers, pre-diabetes, and so on – out to 2 – 5 years.

      And in the adult obesity literature, many studies and systematic reviews likewise show that 5-10% weight loss (i.e. relatively mild weight changes) can lead to improvements in a range of health consequences.

      HELPING PEOPLE WITH EXCESS WEIGHT
      One of my major bug-bears is that, despite the need and the evidence for treatment effectiveness, health systems in most parts of Australia provide very few treatment services for people affected by obesity. Indeed, most health professionals are poorly untrained, or untrained, in the assessment and effective and sensitive management of obesity. This lack of services helps perpetuate such myths as “It’s all my fault”, “Nothing works”, and “I’m a failure”.

      One of the many ways in which people who are already living with the problem of obesity could be helped is by provision of a range of accessible, high quality treatment services in the public health system by well-trained health professionals. I can but dream!

      Some of the interesting sociological questions to address include:
      * Why have health systems been slow to respond to provision of treatment services?
      * Why is there push-back from health professionals towards people suffering from obesity?
      * Why is obesity seen differently in the health system and by health professionals from, say, type 2 diabetes (which is in large part a consequence of obesity)?
      * What are the factors perpetuating obesity stigmatisation in the health system, and in the broader community?

      DON’T BLAME THE INDIVIDUAL
      People involved in the Fact Acceptance movement, and many others – including obesity researchers and obesity treatment professionals – rightly highlight the multiple problems that can and do arise from the way in which obesity can be painted. Sadly, obesity is one of the last bastions of political incorrectness. Indeed, I am reminded of this each week as I listen to the stories of my patients in the clinics for severely obese children and young people that we run at The Children’s Hospital at Westmead. Many experience regular stigmatisation and bullying.

      It’s all too easy for obesity – something which can readily be observed by others – to be labelled as the fault of the individual and as a moral failure.

      So I am in full agreement with you on this. It’s just that I don’t think we should minimise the very real problem of obesity in the process. But that just highlights the challenges of this wicked problem.

      That’s another important sociological question:
      * How can the problem of obesity be addressed without stigmatising individuals affected by obesity?

      ETHICAL ISSUES IN TACKLING OBESITY AT A POPULATION LEVEL
      The following article, published last year in American Journal of Public Health, and by USyd academics, looks at an ethical framework for health promotion, particularly focussed around obesity. I think you’d find it of interest.

      Carter SM, Rychetnik L, Lloyd B, Kerridge IH, Baur LA, Bauman A, Hooker C, Zask A.A framework for health promotion: evidence, ethics and values. Am J Publ Health 2011; 101:465-72. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/21233436

      SOME FINAL COMMENTS
      As I mention above, I agree with your concerns about some of the very negative public discourse on obesity. However, that doesn’t mean we should discount the vast amount of consistent epidemiological and clinical data showing that obesity is a major health problem – for individuals as well as communities. That should not be a point of controversy.

      And as I mentioned in a previous reply, I think the focus for academic and community research and debate should be around the issue of finding solutions to the problem of obesity – in both preventing the problem, and in helping people already affected by it.

      • Thank you again for your considered response, Louise. It is good to know that clinicians are aware of the social and cultural issues around obesity and are working to counter these. You are clearly at the pointy end of dealing with the health effects of extreme obesity, and even the ‘obesity sceptics’ do not deny that extreme levels of obesity are strongly associated with significant health problems (although some of the fat activists do).

        You raise a number of sociological questions which are indeed important to research and discuss. I have read the article by Carter et al. and this was a good start in the bioethics field. But there is also a huge literature in what has now been termed ‘fat studies’ or ‘critical weight studies’ (see the new journal ‘Fat Studies’) published over the past few years which has and continues to interrogate these issues. Sociologists, anthropologists, media and cultural studies researchers, queer theory, feminist and literary studies researchers and historians have all addressed these issues in much detail and depth. I’ve reviewed a lot of this in my forthcoming book (‘Fat’, Routledge), but a quick search of the databases for the social sciences will bring up all the relevant articles.

        Some of the writings I have found useful (among the hundreds available) include:

        Aphramor, L. (2005) ‘Is a weight-centred health framework salutogenic? Some thoughts on unhinging certain dietary ideologies’, Social Theory & Health, 3(4): 315—40.
        Cooper, C. (2010) ‘Fat Studies’: mapping the field’, Sociology Compass, 4(12): 1020—34.
        Evans, J., Rich, R., Davies, B. and Allwood, R. (2008) Education, Disordered Eating and Obesity Discourse: Fat Fabrications, London: Routledge.
        Gard, M.(2010) ‘Truth, belief and the cultural politics of obesity scholarship and public health policy’, Critical Public Health, 21(1): 37—48.
        Holm, S. (2007) ‘Obesity interventions and ethics’, Obesity Reviews, 8(Suppl. 1): 207—10.
        Inthorn, S. and Boyce, T. (2010) ‘”It’s disgusting how much salt you eat!”: television discourses of obesity, health and morality’, International Journal of Cultural Studies, 13(1): 83—100.
        Kirkland, A. (2011) ‘The environmental account of obesity: a case for feminist skepticism’, Signs, 36(2): 463—85.
        Murray, S. (2008) The ‘Fat’ Female Body, Houndsmills: Palgrave Macmillan.
        Warin, M., Turner, K., Moore, V. and Davies, M. (2009) ‘Bodies, mothers and identities: rethinking obesity and the BMI’, Sociology of Health & Illness, 30(1): 97—111.

        I agree that it is very important for cllnicians and public health workers to collaborate with social scientists to seek out the best ways of representing obesity in ways that go beyond focusing on the individual level and bestowing shame, humiliation and social stigma upon people designated as being ‘too fat’. Engaging in this kind of dialogue and exchange of views is a good way to start the process.

      • I think we need to be careful whenever we imply that Fat Activists are ignoring important health issues. I see very little of that kind of denial in the movement; in fact, I think the very term “obesity skeptics” is a misnomer. Even those who decry the use of the word “obesity” are concerned about people’s overall health, although they focus more on the illness and ruinous quality of life that comes from shaming the “obese.”

        Why not afford all people the respect they deserve by addressing their symptoms rather than their size? There are millions of fat people who don’t have joint problems or diabetes and millions of thin people who do. Since focusing on weight loss has shown to be ineffective (would doctors continue to prescribe any other treatment that has a 95% failure rate?) why not focus on movement and healthy eating, regardless of size?

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  8. Can i applaud Louise Baur for taking the time and effort to lay out the responses to the ‘obesity skeptics’ in such a clear and considered way. She has captured all the issues very well indeed. Just as in climate change, it is a challenge for those involved in the science and practice to address all the ‘questions’ raised by the skeptics, who are more often than not journalists pointing out the debates, uncertainties, and imperfections that always accompany a scientific endeavour. These things are the bath water, and we as obesity researchers are wanting to kep the focus on the baby which, by the way, really is getting measurably bigger and really is facing increased health risks.

  9. Obesity and the sceptics

    There is a need for balance in all things, a precept of good health. But there are health risks, and these are denied for a range of reasons by different groups, challenged by others for ideological or academic reasons, and this obesity debate is no exception. The parallels with climate change are strong, the positions polarised, and a sociological or dialectical approach is often to frame a ‘diametrically opposed view’ for academic reasons of intellectual argument.

    First, there is some over-reporting with respect to the obesity ‘epidemic’, but that’s current journalism, and we had the same over-focus with other major health issues; but all of these are undeniable health concerns that occasionally get into the spotlight for a short window of time. This limelight has focused on tobacco, on HIV, on SARS, and now obesity – these are all important health issues that require public health solutions and also good clinical care (and Louise Baur’s perspective seems to encompass both of those).

    But on balance , it is likely that the risk is real; above a BMI of 30, the level usually set for ‘obesity’, the metabolic and joint (arthritis) consequences of obesity are absolutely as real, to a clinician, as the relationship between smoking and lung cancer or smoking and chronic respiratory disease. Also the risks are ‘exponential’ with major weight gain – they really increase rapidly, to a level that is undeniable in a science-based world.

    So the ‘denial’, that “it just isn’t happening, the data are flawed, and the risks are overstated” are a repudiation of the consensus-based on the science of epidemiology, and also of the direct societal observations that Baur suggests one might make in the western suburbs of Sydney [or the southern States of the USA]. A participant observer anthropologist might agree more with epidemiologists here about the presence of the problem !

    Epidemiology is not always right, and it is not values free; but when the evidence lines up consistently and strongly for a risk condition, we tend to accept it. We accept causal relationships for tobacco and health, cholesterol and heart disease, and HIV virus and AIDS; but for each of these there are still dissenters, and this impedes public health action. And there is nothing that the media like more than dissent, as this makes good press, great counterpoint stories, and allows policymakers to delay taking action.

    It seems a shame to be a denier; the counter-arguments may win academic accolades within disciplines, but they confuse the public. If policy makers removed support for obesity prevention work, due to confusion, there would be a major problem still extant [if you believe the data, as I do, that two thirds of Australian adults are overweight or obese], and if de-funded, the problem wouldn’t go away, but we would have no support for preventive interventions.

    It seems that a balanced view is best. We need to be careful not to stigmatise and victim-blame the obese, [particularly as the cues are largely external to individuals, being the food and inactivity environments and policies that we have created and support politically], but we need great care to examine the data and evidence carefully in these situations of substantially increased population health risk.

    And finally, from my own field, some thoughts on the role of physical activity. Yes, its better if obese people are active, and they are undoubtedly healthier if they are active in the usual circumstance that they don’t lose weight. But weight loss is still the main health goal. As we aren’t very good at long term weight loss yet, in our obesity-fuelling environment, then helping obese people to remain active is very important, but its a subsidiary goal. So clinicians and others should promote activity, for its own heath benefits, not only as a part of weight loss. And its just “activity”, moving more, not necessarily ‘fitness’ as Lupton contends. Possibly even more important is the need to increase energy that we expend throughout the day – mostly we now sit too much, and reducing sitting [even by standing at your desk while reading this blog], may be an important strategy in the future.

    To conclude, we live in an evidence based society for health risk and health care. Alternatives, such as homeopathy and iridology, have their supporters, but are not based on the same kind of science. If we live with our predominant science-based paradigm, then you will go to hospital with a heart attack … and then similarly, obesity is a major concern, has major costs, and is potentially preventable.

    This is not the last word, as dissenters will continue to garner fame through controversial writing and books, and have ‘intellectual debates’, and muddy the waters. But that’s all from me. I dont think this merits ongoing ‘argument’ when the perspectives are so divergent, and based on different world views that may never align. So the Monty Python approach, “Do you want to have an argument” (1,2) may be counter-productive to any further progress in this most challenging area of obesity prevention and management.

    Adrian Bauman
    University of Zurich (temporarily)

    [1] http://www.youtube.com/watch?v=kQFKtI6gn9Y
    [2] http://en.wikipedia.org/wiki/The_Argument_Sketch

  10. It is rare for the true believers and ‘skeptics’ to meet face to face in this area of study so I’ll take this opportunity to clarify a few points and correct some errors. In passing, my consistent experience as a ‘skeptic’ is not to have my arguments refuted or shown to lack logic or anything else but simply to be ignored. I do find the accusations of being a “denier” quite odd given that, although reasonably widely cited, I have almost never struck an obesity researcher who’s actually read anything I’ve written. This is their prerogative, of course, but it does suggest that the comparison with climate change is cheap and lazy. Personally, I am offended by the climate change comparison. Refute my arguments by all means, but I am financed by nobody.

    In my most recent book, I make four points which I think are close to irrefutable.

    First, I ignore the journalists and focus on the language of scientific researchers, including a one-time director of the CDC, in which the most preposterous claims are made. I wont’ list them here but they include equating obesity to a global climate disaster (there’s that comparison again) and medieval plague. One scarcely knows what to say about these claims except I am not talking about journalists. This is totally not about a sensationalist media. I mean, in some European cities and countries plague wiped out a quarter of the population in two years. Sometimes I just wish obesity researchers would just read outside their field, just occasionally. It would really, really help. The global change comparison is funny and weird on many levels, but my point is that the obesity research community is so used to making these wild statements that it doesn’t even realise that it’s doing it anymore.

    The important point is that exaggeration matters. The exaggerations of the obesity research community are having perverse consequences throughout society. I invite any of you to cast your eye over some of the bizarre, unethical and frankly inane things that are happening in Australian schools in the name of fighting obesity. As if teachers aren’t busy enough.

    Second, virtually every prediction that has been made about future rates of obesity is not only flat wrong but actually rather silly. There are many reasons for this, including the tendency for researchers to say that obesity “is rising” when in fact they should say “was rising”; after all, data take a while to collect and publish. At any rate, it is now pretty obvious that obesity rates in many – although not quite all – began to level out over a decade ago. In fact, the obesity epidemic as a statistical phenomenon was really over before the medical community got vocal about it. Yes, there is a higher percentage of obese people around. But just about every single prediction about future obesity rates and future associated health costs made in the last 10 years is now – as plain as the nose on your face – a fiction. These predictions only made sense because when accompanied by the words ‘crisis’ and ‘epidemic’ people are less wise with their words and are inclined to believe the unbelievable. But the evidence is now in. Immense exaggeration in the obesity research community just became normal. And to the earlier comment about it being the media’s fault, this is plainly wrong. I have never seen a claim in the media that was not matched by something equally apocalyptic in the research literature.

    Third, as recently as last week the President of the AMA said that we are facing the prospect of obesity causing the children of today to have a shorter life expectancy than their parents. This is one of the silliest pseudo-science factoids ever dreamed up and it is repeated in the scientific literature every day. In my work I have tried to trace the origins of this idea and it seems to have started as a throw away line by some medicos in the late 1990s. It could go back further, who knows, but the important point is that there is not a decent demographer in the world who believes this. Moreover, the very small number of scientific papers making this claim, but particularly Olshansky et al, are so flawed my undergrads can drive bulldozers through them. In fact the Olshansky paper is interesting because despite being so awful, it was published in the NEMJ. But this is what happens when a field is gripped by systemic and exaggerated group think; anything becomes believable.

    Of course, the claim about life expectancy is made by researchers and medicos all over the world about their own country, neatly sidestepping the fact that the only papers that exist on the topic are American. Regarding life expectancy, all the papers I’ve ever read on this matter put increased life expectancy in Western countries down to two things: 50% better medicine and 50% healthier living. Year after year the Aust Inst of Health and Welfare reports that Australians live longer and live healthier. I’m not being tricky and selective. Read the reports, this is what they say. And this is what health authorities – people who don’t just spend their whole time thinking about obesity – all over the Western world say about themselves; we’re healthier than ever. Yes, we could be healthier but how much health is enough?

    Fourth, there is now good evidence across the globe that the steam went out of obesity rates some time ago. Tim Olds has recently shown that childhood overweight and obesity probably stopped going up in Australia in the late 1990s. This is a consistent research finding around the world, even in America. I know people want to keep this quiet but it’s now undeniable. The obesity epidemic – defined as rapid increases in obesity rates – had finished even before the alarm was being raised. I for one am very concerned about some of the data coming out of countries like the Philippines and some African countries but these are different kinds of problems than what has happened in the West; at least different in terms of the policy dynamics that cause rising obesity and the infrastructure in place to deal with it.

    It is undeniable that obesity increased sharply in Western countries over the last 30s from low starting points. I will not deal with the range of claims and counterclaims about what obesity research does or does not show discussed above. It’s late. However, I’m convinced we can now make a few solid judgments based on the data that exist. Yes, being fat is bad for your health. However, for the vast majority of people swept up in statistics like “65% overweight and obese” are just not very fat and being moderately overweight or moderately obese is just not very unhealthy. Yes, if you get massive research samples you can squeeze some statistical significance out of them but being run-of-the-mill overweight or obese is just not that unhealthy. Yes, it’s bit unhealthy but not much. And this is why Westerners are healthier than ever and living longer. As a culture we now do so much that the medical community tells us to do and it just beggars belief when you hear some experts going around saying what a disgraceful lot we are. And by the way, people who study Western health systems have known they are financial unsustainable for about 40 years. Their collapse – and they will collapse – will have nothing to do with obesity and anybody who trots out the “obesity will cripple our health system” line – I’m sorry – has just not bothered to think about what they’re actually saying.

    The obesity epidemic as an issue that was going to galvanise public opinion and provoke Western countries into an “all of government” approach – the holy grail of many obesity researchers – is now fading. The window has closed. Balanced against the over the top rhetoric and bad science that we’ve witnessed in the last decade, people have just realised that obesity is just one of the many mid-level problems we face. The shame of it all is that a great deal of the resources that could have been used to help people who actually needed help, have been wasted trying to push back a “tsunami” that will never come.

  11. Pingback: Can a thin person write about fat? | This Sociological Life

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  14. I have no oppinion on the obesity epidemic, nor am I a scientist of any kind, however, after reading the article above, and the comments that followed I am struck by one thing. Although the many commenters who disagree with the article call upon science to back up their claim, and their claim might very well be right, they put up a front which is more religious then anything else. What I mean specifically is this, they discount completely the skeptics view while at the same time using language evocative of superiority, or authority. The idea that their might be an alternative view to their view with regards to obesity is seen, and this is made clear by their language, as a sort of heresy. There is such a strong belief that obesity causes various health effects among the commenters who disagree with the article that it makes me personally wonder who are the “true believers” I think it’s clear the obesity has had a tremendous negative effect on the population of the U.S. and have no criticism of the idea that obesity causes various health problems. But it is frightning how fiercely people have faught the author of this article. Science should be a dispassionate review of evidence at the end of which a conclusion is drawn. Furthermore, at any point that conclusion can be refuted, and argued against. However, it is clear that the commenters above are emotionally invested in their beliefs with regards to obesity. Indeed they come off similairly to a devoutly religious person when confronted by an athiest.

    • Yes, you are quite right when you observe the emotions underpinning the various sides of the obesity science debate. Both sides believe passionately in their position and in some cases can be quite evangelical in putting it forward and arguing against others’ views.

  15. I have to be honest. The comments were far more valuable than the article itself – which was already a good read. Thanks for the good and civilized talk, it surr helped me understand a lot about obesity.

    About a comment I saw earlier that complained about the ferocity in which this article has been criticized, i think its really easy to understand: imagine someone claiming that the earth was hollow. Would you not argue in the same way? The thing is, when it comes about science, personal preferences are worthless when one faces hard facts. Reality is just one, not many, and suffers no influence from personal wishes. Which means that scientific inquiry is our best shot to understand it. Views that deny hard facts are not scientific, and hence, poorly represent reality. In conclusion They are not entitled to any respect, considering, of course, the mind of a person that denies obesity skepticism..

    The angry responses, in my view, comes from the fact that when a group defends a delusional view (like creationism) and demands equal treatment of their ideas, it holds progress back for everyone, which is, understandbly, frustrating.

    But those are only my opinions. I wish not to provoke animosities with the proponents of obesity skepticism. And, as a matter of fact, i will read the three books recomended (since the article was a brief summary of them). I was just trying to explain where the hostility comes from.

    • I think one of the biggest problems with the science is simply the use of statistics. Statistics can be a very valuable tool to forming a picture of how things work, but often times conclusions are drawn far too early. There is a segnificant difference between someone supporting creationism saying “The Bible Says So” and someone supporitng the idea that maybe obesity isn’t as huge a problem as its been played out to be by showing cases in which the obesity hypothese doesn’t hold true. I have not read the books cited in the original article but I believe that the autor points out that the authors of the books don’t just say “Because I said so…” rather they point to studies which break down demographic data differently and show a different result. This is not counter to science it is actually the heart of science.

      Using reason and critical thinking, while reviewing conflicting scientific evidence is not akin to a religious person preaching creationism, rather it is best scientific practice. Indeed it is the dismissal outright of the conflicting data which shows the bias and non-scientific point of view in its raw shallow nudity.

  16. Thanks for this lovely and informed discussion. I recently posted a forthcoming article entitled “The Right to be Fat,” which discusses the legitimacy of governmental policies to encourage weight loss. While it surveys the critical literature this post mentions, it is not dependent on it for its argument. That is, it maintains that even if fatness is unhealthy and not predetermined by genetics and other factors, body size should still be recognized as a matter of liberty and autonomy, without the interference of the state or society. To download the article see link below.

  17. Pingback: Spreading holiday cheer by debunking health-care myths | Cape Breton Independent

  18. Pingback: Week 5: Food & the body (Hite) – Food Matters

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