Continued from part 1:
…For health practitioners, particularly those enamoured with biochemical indices and relative-risk reduction strategies, the notion of one, simple solution [weight loss] to a myriad of chronic diseases — and possibly to mortality itself — is eminently seductive.
Sadly, I also think it’s wrong.
Why is it wrong?
Because, first of all, weight isn’t equivalent to health. And therefore, weight loss isn’t equivalent to automatically improving health. But I think we all know that.
More complicatedly, weight isn’t even the most important factor in determining a person’s health. And this is an idea that I think might encounter some resistance. But I’m totally serious.
(And I’m sorry if this is all a little too “Public Health 101” for everyone, but bear with me. All that theoretical crap I learned in school actually DOES, it turns out, have relevance.)
I propose that the insistence on “obesity” as a personal failing, and even the conceptualization of “obesity” as a disease, is actually an artifact of an individualist perspective of health. Which is to say, because we tend to believe (as Americans, as North Americans, and sometimes just as humans) that health is an individual issue, not a social or public one, we revert to blaming individuals for all kinds of conditions and illnesses that do not jibe with our cultural ideals of What A Person Should Be.
But if you start to look at health as more than just a personal balance sheet of good behaviours vs. bad behaviours, and even look beyond genetic underpinnings, or plain roll-of-the-dice random luck, you’ll see that there are broad, societal patterns of who gets sick and who stays well. And thus, we run smack-dab into the concept of Social Determinants of Health.
If fat people experience poorer health than other people — and there are stacks of epidemiological associations that imply we do, the lower mortality risk of “overweight” people notwithstanding — then maybe it would be useful to put down the keys to the blame-mobile for just a moment and consider one question:
Now, if “obesity” were one of those things that had a single cause, and a single mechanism, and, subsequently, a single, reliable cure — then maybe it would be fair to jump instantly to the conclusion that being fat, itself, is the problem. (And, naturally, losing weight would be the magic-bullet cure.)
Except it doesn’t work that way.
At present, we’ve got so many hypotheses for why people get fat that you could drive yourself crazy trying to read it all. There’s, you know, adenoviruses, and some kind of woo-woo social transmission by which your being fat tacitly encourages your friends to get fat, and there’s the leptin-deficiency hypothesis which turned out not to apply as easily to humans as it did to specially-bred mice, and the whole food addiction thing, the obesogenic environment thing, the evil-carbohydrates thing, and then the genetic component (which, in itself, seems to implicate so many different genes that I don’t think you’d be able to find a police station long enough to accommodate a line-up.)
Fatness, it turns out, is a many-splendoured thing.
And, as a result, we’ve never found that wonderful magic-bullet cure I mentioned, even though people will swear up and down on their life, on their Bibles, on their mother’s-mother’s-mother’s grave, that we have.
In that case, I have only to ask: then why are so many of us — most of whom desperately don’t want to be — still fat?
Because there isn’t a single “Cure.” Because there isn’t a single cause or mechanism. And, not least of all, because fatness isn’t a disease.
A quote I love:
My definition of a disease is a categorization…that has predictive power and, in some cases, enables causal inferences to be made. There remains the difficult but not insoluble problem of distinguishing disease from social deviance.
-Ian R. McWhinney, CMAJ, VOL. 136, APRIL 15, 1987
I’m preeeeetty sure that the whole OMGBESITY CRISIS!!!! is actually more about policing social deviance than it is about concern for our health.
And even if fat people are at higher risk for certain diseases, I still contend that fatness itself isn’t the problem.
So what is?
I posit that the problem is social inequity. To wit: marginalized people have poorer health outcomes.
Are fat people marginalized? You betcha.
Does it affect our health? Quite possibly.
As always, let’s hash it all out in comments.