What's Wrong With Fat? (10 page)

Not only did the 2000 WHO report legitimize the obesity epidemic label, but also it gave official standing to the use of BMI as a measure of obesity.
The 1995 WHO report had explicitly rejected BMI as a measure of obesity, on the grounds that BMI does not measure fat mass or percentage. 73 In contrast, the 1998/2000 IOTF-WHO report designated three categories of obesity based on BMI, including: “Obese class I: BMI 30–34.9,” “Obese class II: BMI 35–39.9,” and “Obese class III: BMI ³ 40” and recommended weight loss for everyone with a BMI greater than 30. In addition to touting “dietary, physical, activity and other health lifestyle changes,” it also stated that “drug therapy and surgery can be considered as adjuvant therapy for obese individuals who fail to respond to primary management approaches.” 74
Through use of the word
obesity
,
which has a stronger clinical connotation than
overweight
,
paired with the use of BMI as a measure, this report helped transform fatness into a public health crisis.

Since then, the IOTF has continued to promote the public health crisis frame. In 2003, the IOTF made a major presentation to European Union (EU) health ministers in Milan, delivering “Obesity in Europe 2—Waiting for a Green Light for Health,” which characterized obesity as “a pandemic with major economic as well as health consequences that are increasing the burden of chronic non-communicable diseases throughout Europe.” 75
The IOTF has also drawn attention to a “childhood obesity epidemic.”
This organization recommended an international criteria for measuring “overweight” and “obesity” in children that could be used to document cross-national trends and trends over time. 76 The IOTF has actively collaborated with states in Europe and elsewhere to bring attention to this issue. 77

In France, Roche Pharmaceuticals has directly funded, in collaboration with the French National Institute of Health and Medical Research (INSERM), a longitudinal national survey on overweight and obesity in France among those 15 years and older called ObÉpi. This survey, which includes waves from 1997, 2000, 2003, 2006, and 2009, has been critical for establishing the idea that obesity is increasing at epidemic proportions in France, even though rates of obesity remain relatively low in France. 78

One way to create the perception that increasing numbers of people are affected by a condition or disease is by changing the way the disease is defined so that it is more inclusive. Thus, if rates of autism, attention-deficit/hyperactivity disorder, depression, and obsessive-compulsive disorder (OCD) have seemingly skyrocketed in recent years, some scholars argue that this is largely because of looser criteria of diagnosis, which, in turn, increase the number of people who fall into the disease category. 79 While there have been real increases in population BMI, the criteria for overweight have also became more inclusive over time. Specifically, as discussed in the previous chapter, in 1998, the NIH lowered the cutoff for overweight from a BMI of 27.8 in men and 27.3 in women to a BMI of 25 for both. This caused 29 million Americans to become overweight overnight. 80

Similarly, in 2000, the IOTF assigned lower cutoffs for overweight in Asians based on the argument that “the medical impact of even modest weight gain was greater among these populations than in others.” The 2000 IASO-IOTF-WHO report entitled “The Asia-Pacific Perspective: Redefining Obesity and Its Treatment” recommended “in Asians,” a cutoff of BMI greater than 23 for overweight and a BMI greater than 25 for obesity. 81 The WHO abandoned these new guidelines two years later, however, after a subsequent consultation concluded that there was too much variation among different Asian populations regarding the cutoff for predicted risk. 82
Still, this points to the contested nature of body mass categories, on which the notion of an epidemic depends.

The important role played by IOTF in shaping obesity policies and guidelines at the national and international level is consistent with a more general trend in which pharmaceutical companies are increasingly defining diseases and dictating health policy and medical protocol for a wide range of conditions. 83 As bioethicist Carl Elliot puts it, a pharmaceutical public relations strategy that has existed since the 1950s, but has become more common in the 1990s, is selling a treatment by selling a disease: “To sell Prilosec, you have to sell acid reflux; to sell Lotronex, you have to sell irritable bowel syndrome; to sell Viagra, you have to sell erectile dysfunction; to sell Adderall, you have to sell ADHD. You market a treatment by convincing doctors and patients to diagnose the illness that your drug or procedure treats.” 84 Similarly, in
Selling Sickness
,
journalist Ray Moynihan and drug policy researcher Alan Cassels show that drug manufacturers now fund the bulk of clinical trials on new medication; sponsor the scientific meetings, events, and conferences where this research is presented; and underwrite the medical societies and patient groups that then go on to cite this research as justification for taking policy action. 85 Elliot shows how advocacy groups are commonly used to raise awareness about conditions for which their pharmaceutical sponsor sells a pharmacological treatment.
He cites an early example of the Human Growth Foundation, a nonprofit charity based in Virginia whose aim is to raise awareness about growth disorders among teachers and parents. Human Growth Foundation is funded by Genentech and Eli Lilly, which both manufacture synthetic growth hormone. 86
While a patient advocacy group backed by a pharmaceutical company was seen as scandalous in the 1990s, he argues, today it is the norm.

Even obesity researchers who rely solely on public funding are often drawn to a health crisis framing of fat, in that, in an increasingly competitive grant environment, this frame effectively establishes the urgency of obesity research. 87 And as obesity has become a growing public concern and there have been more public research funds available for research in this area, this has encouraged more researchers to study obesity within a paradigm in which it is assumed that fatness represents a medical and public health problem. As obesity researcher James Hill puts it, “you tend to focus on things that you think NIH [National Institutes of Health] is interested in, so if they have an RFA [Request for Applications] out for this particular area, you focus your work toward that area.” And NIH funding for obesity has skyrocketed, from about $50 million in 1993 to more than $400 million in 2004. 88

HEALTH AT EVERY SIZE

In direct response to the medical and public health crisis frames, the health at every size frame argues that the contemporary emphasis on weight loss is wrongheaded. Health at Every Size, or HAES, is a registered trademark of the Association for Size Diversity and Health (ASDAH) since August 2011.
The frame, however, can be traced back to at least the 1970s. “Dieting is the cure that doesn’t work for the disease that doesn’t exist,” the 1970s fat acceptance group, the Fat Underground (FU), used to say. 89 Or, as the inside jacket of Linda Bacon’s book
Health at Every Size
puts it, “Fat isn’t the problem. Dieting is the problem. A society that rejects anyone whose body shape or size doesn’t match an impossible ideal is the problem. A medical establishment that equates ‘thin’ with ‘healthy’ is the problem.” 90

According to a health at every size frame, the real problem is not fat itself but the focus on weight loss and dieting. HAES supporters point to studies showing that the overwhelming majority of dieters end up regaining all they lose and often more, worsening their health in the process. 91 A health at every size frame asserts that weight is a poor proxy for health, and people across the size spectrum can become healthier without intentional weight loss. Advocates point to epidemiological studies showing that rates of mortality only increase in the very highest (and lowest) extremes of BMI, so that people who are “overweight” or “moderately obese” are not at heightened risk of mortality. 92 They point to studies showing that, among those who already have cardiovascular disease, those who have a BMI in the obese range have
lower
rates of mortality. 93

They further point out that, even at the highest-level BMIs, which are
associated
with higher mortality, it is not clear that elevated mortality is actually
caused
by high BMI. Instead, other unmeasured factors, such as poor nutrition, sedentary lifestyle, poverty, and weight-based stigma, may be the root cause of both higher BMI and of higher mortality and/or morbidity. 94 They advocate focusing on those root causes, and especially sedentary lifestyle and nutrition, rather than on weight per se. They emphasize
weight neutrality
,
or the idea that people might gain or lose weight when practicing a HAES approach, but that this is not the intended or pursued outcome. Like the medical and public health crisis frames, the health at every size frame draws upon a master frame of health. However, it challenges the idea that fatness is automatically pathological and that weight loss promotes health.

While its supporters often present HAES as novel and its detractors suggest it is marginal, one actually finds elements of a health at every size frame in earlier authoritative health documents. For instance, a 1995 WHO report, written before the existence of the IOTF, opines: “Weight loss in overweight is difficult to sustain, is still of uncertain benefit to health in the long term, and may lead to weight cycling.” 95 This report explicitly notes the limited research linking specific BMI cutoffs among adolescents to health risks, makes no mention of an “obesity epidemic,” does not encourage weight loss per se, and does not evoke drug therapy or surgery.

More recently, exercise physiologist Glenn Gaesser has championed a health at every size frame, writing that “people should be physically active, eat healthy foods, and not obsess about the numbers on the scale.” 96 Gaesser argues that physical activity and a diet high in fiber and complex carbohydrates and low in fat and sugar are more directly linked to good health than is weight and that improving diet and becoming more active do
not
always translate into weight loss for all people. He points to research showing that one can be “fit and fat” just as one can be unfit and thin and that it is fitness—not weight—that matters. 97

Gaesser heavily cites Steven Blair, who is professor of exercise science and has published scores of peer-review articles in leading scientific journals including the
Journal of the American Medical Association
(
JAMA
) showing that physical fitness better predicts health outcomes than BMI. In fact, Blair’s work has shown that, among people with the same level of physical fitness, BMI has no effect on mortality from all causes. 98 Blair says that he believes that “obesity travels in bad company,” in that it is associated with higher rates of diabetes, heart disease, and knee osteoarthritis, but that obesity itself is “the wrong target” of health interventions. The target, he says, “should be on lifestyle,” including a “healthful diet and regular physical activity.” He expresses frustration with the disproportionate focus on energy intake and relative inattention to physical expenditure in the literature on obesity and is adamant that “it’s inexcusable now for scientists to study obesity and not to take physical activity, carefully measured or cardiorespiratory fitness, into account.”

A family nurse practitioner and member of NAAFA talks about how she brings a health at every size frame to bear on her clinical practice: “I never tell my patients to lose weight. I think that it’s a horrible thing to tell people: ‘Oh, you have to lose weight.’ I do encourage my patients strongly to make healthy choices in eating, and I try to encourage them to exercise, because I really do believe that you can be fat and you can be fit.” While a medical frame likens fat to cancer and smoking and a public health crisis frame likens fat to an epidemic, according to a health at every size frame, fat itself is largely irrelevant to health. Espousing this perspective, political scientist Eric Oliver argues that the connection between fat and cardiovascular disease may be the same as the connection between yellow teeth and lung cancer: “Based on our current evidence, blaming obesity for heart disease, cancer, or many other ailments is like blaming smelly clothes, yellow teeth, or bad breath for lung cancer instead of cigarettes; it conflates an associated trait with its underlying cause.” 99 As far as I know, Oliver is the only one to compare fatness to yellow teeth. However, this analogy is consistent with what could be called a HAES mantra: association does not equal causation.

Nutritionist Linda Bacon likens fatness to baldness to make the same point in
Health at Every Size
: “It is well established through epidemiological research that bald men have a higher incidence of heart disease than men with a full head of hair. However, this doesn’t mean that baldness promotes heart disease or that hair protects against heart disease. Nor is it recommended that bald men try to grow hair or buy toupees in order to lessen their disease risk. Instead, further research indicates that high levels of testosterone may promote both baldness and heart disease.” 100 While fat is likened to yellow teeth and baldness to make a specific point about association versus causation, it is nonetheless revealing that neither yellow teeth nor baldness are especially positive characteristics. While strongly disputing that fatness is, in and of itself, a risk factor and or disease, the health at every size frame does not offer an alternative positive interpretation of fat. The health at every size frame does not assert that fat is beautiful or that fat is necessarily healthy. Rather it makes a weaker claim: that one
can
be fat and healthy, just as one can be thin and unhealthy. It neutralizes, without inverting the stigma associated with fatness. 101