Fatness, Health, & Uncertainty

By Daniel Goldberg

Reading Nir’s thought-provoking post below sparked a couple of thoughts in my mind regarding fatness, ethics, and population health.  The first is what I take to be the professional obligation to engage seriously with the epidemiologic uncertainty regarding the connections between fatness and health.  With notable exceptions — see the Rudd Center, for example — most of the work in bioethics and law that discusses obesity problems does so by averring (1) that obesity is an enormous problem for public health; and then (2) proceeding to discuss a particular intervention intended to ameliorate it.  But I generally perceive all too much haste with the first step.

There is a growing amount of scholarship in fields like fatness studies and critical obesity studies that engages the epidemiology regarding fatness and health on its own terms, and points out how much uncertainty there is regarding the connection.  Just recently, the so-called ‘obesity paradox’ — that in some populations increased adiposity is actually protective of health — has made waves in the mass media and in the pages of major medical journals, but in point of fact the latest studies merely confirm the evidence on the subject that has been available for some time.

The single most rigorous investigation of the significant uncertainty in the fatness-health connection is Gard & Wright’s 2005 book, The Obesity Epidemic (ironically titled, of course), in which they examine over 1200 food science studies to demonstrate said uncertainty.  There is nothing wrong with the latter — it inheres in epidemiology — but the question I have always been struck with centers on the significant disconnect between the extent of the uncertainty and the certitude with which public and even professional discourse on fatness and public health proceeds apace in the West.  Gard and Wright argue convincingly that ideologies and constructions of fatness are critical to explaining the divergence.

In any event, what is the takeaway for bioethicists and health scholars working on fatness and obesity? First, I think the existence of significant epidemiologic uncertainty must be engaged.  This is not to suggest that morbid obesity is good for population health — indeed, morbid anything is by definition bad for health.  Rather, and given the rapidly moving goalposts of BMI, I would argue that we cannot evaluate the merits of any given intervention for remediating fatness without interrogating rigorously our evaluation of the extent to which it is high-priority problem.  I am not prescribing what anyone’s answer here ought to be — merely that the uncertainty must be enjoined.  The movements of fat acceptance and health at every size cannot blithely be dismissed as evidence-free grass-roots advocacy campaigns; there is decent epidemiologic evidence that buttresses the approaches, goals, and objectives of these social movements.

Second, and related, when the existence of fat bodies is treated primarily as a problem to be corrected, we run into significant and welldocumented problem of fat stigma.  It is of course possible to regard obesity as a significant health problem without resorting to the stigmatization of fat persons, but the history of health stigma shows how common it is for public health practices and programs to channel and execute stigmatizing attitudes, beliefs, and practices against those deemed to have spoiled identities.  If it is at least possible that the scope and tone of national discourse on obesity and fatness incorporates stigmatizing social constructions on the subject, then ensuring we are sensitive to the complexities of the evidence is one responsible way of proceeding.  Stigma is corrosive and IMO is rarely if ever justified in the name of public health (although there is disagreement on this, as Nir and I have discussed!), but in the case of fatness it also is demonstrably counterproductive (see Puhl & Heuer 2010).

There is a third point, one related to the social gradients of so-called risky health behaviors — that the fundamental causes of obesity-related diseases are much more likely to be the social and economic conditions that largely determine which groups are more likely to engage in such behaviors than others.  But I’ll save this last point for the next post!


0 thoughts to “Fatness, Health, & Uncertainty”

  1. Daniel,

    Nice to see you blogging here!

    On the “stigma” point, I was both surprised and happy to see an article in today’s LA Times (by Melissa Healy) that noted “health campaigns that make people feel shame may backfire, researchers say.” The article quotes from Rebecca Puhl of Yale University’s Rudd Center for Food Policy and Obesity, who states: “We find that people actually cope with stigma by eating more food.” Public health campaigns that focused on getting people, among other things, to “eat better” while leaving out references to obesity were said to be more effective if only because “obese subjects were likely to perceive shame and stigma more strongly and more often than their slimmer counterparts.” See: http://www.latimes.com/news/science/la-sci-obesity-20120912,0,5230176.story

    1. Hi Patrick,

      Thanks much for the kind words, and the link to the timely article. I love Rebecca Puhl’s work; she’s amazing. One interesting note, though, is separating the descriptive from the normative in thinking about fat stigma. The Times article focuses on the fact that shaming fat people does not work, that it is likely to increase fatness.

      But what if it did work? Does it follow that we ought to stigmatize people? This is not merely a hypothetical, since contra to the fatness case, stigmatizing smoking almost certainly has contributed to the general decline in smoking incidence in the U.S. That’s the subject of the debate I linked to above between Ronald Bayer and Scott Burris — whether it is ethically defensible to wield stigma as a tool if in fact it produce salutary health consequences.

      Fodder for another post!

  2. Oh, and I should note that I’m delighted you’ll (re)turn to the “social determinants of health” subject, a topic that inititiated some vigorous online debate recently at 3 Quarks Daily: http://www.3quarksdaily.com/3quarksdaily/2012/08/health-care-reform-does-not-start-in-your-kitchen.html#more

    [And the picture to the left of my comment is of course not me, but the late and great Kenneth Rexroth, whose last wife, the poet Carol Tinker, recently died here in Santa Barbara.]

  3. Great that you’re blogging here, Daniel!

    Regarding obesity stigma: quibbles about the exact cut-off point between overweight and obese, and about some movement in the goal posts aside, presumably you are not denying the bulk of the following important truth: that EITHER being overweight OR being obese “substantially raises… risk of morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality.” (http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf)? I agree that stating and acting on this important truth is tricky: to do so runs some risk of exacerbating stigma, and exacerbating it is usually counterproductive. But surely that trickiness does not make the truth untrue.


  4. Hi Nir,

    I believe — hope? — that it is possible to acknowledge the significant complexity of the statement you quote without denying its truth. Obesity is of course associated with all manner of health problems, and yet in some populations, obesity is actually protective of health, as noted in the original post.

    It seems to me that these two statements are quite compatible, but that if so the fatness-health connection is far more complicated and uncertain than is typically allowed for. We cannot tell when looking at an individual fat person whether they are in fact unhealthy simply by looking at them. No?

    (And for the record, I do not think we can regard moving goalposts as mere quibbles, see Jeremy Greene’s nice book, http://bit.ly/TPzIz3).

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.