The Problem with Health at Every Size
There is a difference between coddling and compassion.
Approximately one-third of the North American population is obese, and a significant number of them are suffering as a result. One of the things they suffer from is fat shaming, which, as I pointed out in this piece, seems to be the last acceptable form of prejudice.
They (again: many, not all) also suffer from a series of negative health consequences that is directly related to their body weight. And so, the term Health at Every Size (HAES) is an oxymoron.
It’s an oxymoron because the research is clear that higher body fat – specifically abdominal obesity – is directly related to poorer health outcomes.
On November 13, 2014 in my Chicago Tribune column I had an article published entitled: “Can you be overweight and healthy?” I approached that column without much in the way of preconceived notions. I wanted to uncover if the body fat itself was unhealthy, or just the lifestyle that often coincides with its accumulation. I knew of the HAES position on this and sought out advocate Linda Bacon for her side of the story.
It was a challenging interview, and the longest of all four I conducted for the article (Dr. Yoni Freedhoff, Dr. Arya Sharma and Dr. David Katz were also interviewed).
I struggled to understand her position. I went into that interview determined to hear her out and give her the chance to make her case regarding how obesity is not a health issue that we should be concerning ourselves with, and that the medical establishment should stop encouraging people to lose weight.
The reality is Linda Bacon failed to make her case. I endeavored to see the logic of her arguments, but there wasn’t much logic there. Conversely, Dr. Freedhoff, Dr. Sharma and Dr. Katz, plus the additional research I cited in the article, all provided compelling evidence that abdominal obesity all by itself is very much a health concern, independent of lifestyle. I went into this article thinking excess body fat might not be so bad, and came out of it realizing that it’s worse than most people believe. (Although there are obese people who are healthy.)
As a result, Bacon was not pleased with what I wrote, and she complained. A correction was issued on December 9 regarding that column, which I include below:
… James S. Fell paraphrased nutrition professor Linda Bacon of the City College of San Francisco as saying “that being overweight is healthier.” Bacon did not say that; she said that most epidemiological studies on longevity have shown that overweight people live longest. The column also said that Bacon cited 5 percent as the number of people for whom weight loss would be sustained if they attempted it. She did mention the 5 percent figure in the discussion but did not make that conclusion. A paraphrase suggesting that she believes “burning fat causes inflammation” differed from her statement, which was, “Even during short-term dietary restriction, while people are on a diet, there is increased inflammation in the blood.”
There is much more to the story than what this correction states, and it reveals Linda Bacon as a … well, I’ll let you draw your own conclusions. In regards to the issuing of said correction, I will not comment on the Chicago Tribune’s decision to do so. I will merely state that I provided the relevant transcripts of my interview with Linda Bacon to my editor.
Although Freedhoff, Sharma and Katz all praised the piece (as did the author of a study I cited), Linda Bacon took issue with every instance of paraphrasing in that article, but before we get to that I wish to share an exchange that took place after my article was published.
Linda started off by posting on Twitter: “No, I don’t endorse much attributed to me in Chicago Trib … let’s call for responsible journalism.” I was not impressed, and so I sent a reply reminding Linda that I had a voice recording of our conversation and that the quotes were accurate and in context. She then sent me two more emails, which I did not reply to because of her hostile tweet, that were more apologetic in tone. Bacon did reiterate that she felt she had been misrepresented, but these quotes from her were included:
- “I could certainly understand why you might feel bad – I attacked your reputation. And what I get in all this is that we both acted with integrity and tried to do what we thought was right.”
- “I’m sorry to have tweeted what must have been hurtful.”
- “I’m sure two people could listen to that voice recording and hear very different things.”
In regards to that last one, let’s go through the transcripts, and you can decide what you’re hearing.
“Bacon and others claim that being overweight is healthier because of comparisons of body weight at time of death.”
Linda Bacon’s quotes:
“There have been about 40 epidemiological studies that have been done on longevity and all but a handful of them are showing that people in the overweight category live the longest, so you need to relook at the data. But if you look at the vast majority of data that’s out there, it’s pretty clear that there isn’t any way a scientist can argue. If you look at a review of all the data we have on mortality, we have the vast majority of stuff shows the people in the overweight category live the longest. And they show most levels of obesity, mild to moderate obesity, live as long as normal weight. And I really don’t think that’s disputable from the evidence.”
Did I take some artistic liberties by inferring that “overweight is healthier” because Bacon quotes a bunch of research stating that those who are overweight live the longest? In this context, is having the most longevity not a good definition of being the healthiest? You decide.
Also take note of the evidence in my article that the claim about overweight people living the longest is a gross misrepresentation of the data.
“Bacon argued that most people won’t succeed at weight loss, asserting that only 5 percent can sustain it.”
Linda Bacon’s Comments (emphasis mine):
“There is always of course the small percentage of the population that … it might result in sustained weight loss. But every time it’s been tested for the vast majority of people, all the methods we have don’t result in sustained weight loss.
“If you look at the number of people in the registry (the National Weight Control Registry of people who have been successful at sustained weight loss), it’s probably like one one-millionth of the people who are actually dieting, so it’s not representative of the major result. It’s very tiny.
“They define long-term weight loss as one year. The research studies are showing that 2/3s of the people are able to keep things off at one year, but if you follow them out to five years, the majority of them have put it back on. Even those things that say just drop your calories a little bit or go exercise that kind of stuff is still not showing any difference. We still don’t see any sustained weight loss from it.”
At this point I asked Linda a question about the examples of people for who sustained weight loss did work. This was her direct reply to that question:
“There are statistical anomalies. When something works for 5% of the population you can’t say that therefore prescribing it for everybody is going to work. Instead what you got to do is look at what is particular about that 5% of the population, and I’m sure that we can find things that explain their particular circumstances. But it has to do with those individuals, not with the diet idea being effective. There are always going to be people who are statistical anomalies.”
The 5% figure is one of those urban legends that have been thrown around for years, akin to saying we only use 10% of our brains. There is research to actually back up this claim, but the percentage is based on including every fad and gimmicky diet / exercise contraption, so it is not a fair analysis of what happens when people go on a more logical path to weight loss using an evidence-based medicine approach. However, Linda also commented that she saw no difference in terms of the approach to weight loss that is taken. Here is a direct quote from my interview with her: “I don’t think there is much difference between the fad diets and things that are more conventionally recommended.”
But Linda took issue with me paraphrasing her as “asserting that only 5% can sustain it.” And yet she says “small percentage” and “one one-millionth” (which is actually only 0.00001%) and that the percentage is “very tiny.” More telling is that I specifically asked her about people for whom sustained weight loss did work and she referred to them as “statistical anomalies” twice, and twice made reference to the 5% figure.
So, is my paraphrase a misrepresentation? Again, you decide.
“burning fat causes inflammation, which can worsen diabetes”
Linda Bacon’s Comments:
“Even during short-term dietary restriction, while people are on a diet, there is increased inflammation in the blood. I can give you a research citation that shows that. So, we know that one of the issues with diabetes is increased inflammation. That’s one of the things that cause diabetes. So that diet they’re doing – their eating less – may be worsening their diabetes.”
Dietary restriction is a direct cause of burning fat. This is simple physics based on the first law of thermodynamics. I admit to tightening up the association in order to meet print space requirements.
What About Those Other Quotes?
Here are quotes in my article that are direct attributions to Linda Bacon that she did not dispute. She only disputed (all of) the paraphrasing:
- “I don’t think there are demonstrated benefits to weight loss.”
- She called those who do succeed (at weight loss) “statistical anomalies” whose habits are “akin to eating-disordered behavior and extreme amounts of exercise.”
From the interview but not included in the article, regarding encouraging weight loss, she said, “It’s telling people there is something wrong with your body. I think it’s unethical given what we know. We have no known methods that work.”
So What’s the Problem with HAES?
It took a lot of words to explain the story behind Linda’s complaints regarding my article and the subsequent correction, but in so doing I’ve revealed a lack of logic and plain dealing behind a primary advocate for HAES.
In my interview with Dr. Yoni Freedhoff, we discussed many things in regards to HAES that I unfortunately did not have room to include in my Tribune article. These quotes from that interview are published here with his permission:
Dr. Freedhoff on the feasibility of weight loss:
“To suggest that people are incapable of loss long-term is plainly false. There are plenty of people who lose weight long-term. What is plainly true is that the vast majority of people who go on stupid diets gain the weight back … So don’t do something stupid and focus on lifestyle. Losing weight and keeping it off is very doable.”
Dr. Freedhoff in regards to Linda Bacon and HAES:
“She holds out nonsensical research to support her opinions; anything that supports her confirmation bias she is happy to promote. To say that you can’t be against fat shaming and support losing weight is not true, and to say that losing weight has no benefit is not true.
“It is a problematic stance that the more militant members of the HAES community has. Not everyone feels the way she does. In many of the things she talks about I agree with her, but there isn’t a lot of scientific support for HAES. Lumping every stupid diet program and stupid research study into weight loss fails is not the right way to go about it. We don’t have a gold standard. There are awful programs and awful studies. It doesn’t mean weight loss is impossible and it doesn’t mean it’s not helpful. HAES says the numbers of people dying from obesity is exaggerated, but it’s still a lot. I would ask how many deaths it takes for it to be something to be concerned about. No one can deny there are deaths. Even being really conservative we’re still talking about tens of thousands of deaths per year.”
Dr. Freedhoff in regards to HAES and promotion of size acceptance:
“HAES has not done good things in terms of size acceptance. Unfortunately, HAES is like the choir talking to itself. It isn’t about dialogue and discussion, but instead confrontation and anger. That shuts down conversation. It alienates people. And it gives people who feel negative towards HAES to begin with more reasons to feel negative. There is zealotry involved. You’re not furthering your cause. You’re preaching to the converted so everyone can clap their hands, but they were already the hands that were clapping. There are no new hands there.”
Read this article by Dr. Yoni Freedhoff for more information about the folly of the HAES approach.
Undermining Size Acceptance
A few weeks ago a HAES blogger went on a lengthy, factually inaccurate attack on my character. Much of his article focused on the correction issued by the Tribune, saying it was a hatchet job against HAES. As I’ve pointed out in this piece, it was no such thing.
HAES does the hatchet job on itself by spreading bad information about obesity and the feasibility of sustained weight loss.
The blogger, whose name I will not mention and whose piece I will not link to, made myriad personal attacks that were blatantly false. He then continued to make silly (and easily exposed as inaccurate) attacks against me on Facebook. I spent some time defending myself on his Facebook page, and even said I would expose all his mistakes in a future post, but have since realized he’s not worth my time. The primary accusations were in regards to my interview with Linda, and that defense is now complete.
But the real issue here is that, despite what this blogger falsely asserts, I am a champion of size acceptance; I can reference numerous articles and Facebook posts that prove I have battled fat shaming for years. And I’m doing a better job of it than HAES is, because I’m not deluding people. When you make false claims about obesity, and assert that attempting to lose weight is dangerous / worthless / a lost cause, you’re undermining all the potentially good work you could do in the battle against fat shaming.
When most people see you claiming that obesity is healthy, and that succeeding at weight loss is virtually impossible, they stop listening. Like Dr. Freedhoff said, HAES is only preaching to the converted a false message of “Can’t win, don’t try” in regards to weight loss. And so, the important message of size acceptance and combating fat shaming is undermined.
Should We Accept All Sizes?
Yes, we absolutely should.
Another person’s body weight is not your concern. As I wrote here, I’m disgusted by some ultra-lean mom saying, “What’s your excuse?” for not being fit. Yes, obesity is a public health concern, but the research overwhelmingly shows that this has been caused by the creation of an obesigenic environment. The typical person is not to blame for being obese. Instead, we should be targeting misuse of government subsidies and unethical practices by food corporations and a corrupt weight loss industry that all make it easy to gain weight, and difficult to lose it.
I ride my bike and run on highways with no shoulder. I downhill ski through trees at high speed. I drink. I do heavy bench press in my basement without a spotter. Sometimes, I drive a little fast. I once traveled through rural Guatemala and came into direct contact with rebel soldiers. I jump off high cliffs into freezing cold water and do a bunch of other stupid guy stuff that might get me injured or even killed.
I do things that are dangerous to my health, things that might end up costing the healthcare system money. And it’s none of your damn business!
It’s my life, and I can do with it as I please. I need to answer to my immediate family and me. The person I discuss my health with is my family physician. I have the right to demand that other people not care how I live my life, regardless of my weight.
You don’t have the right to tell people how to live their lives, regardless of their weight.
Yeah, but fat people drive up healthcare costs.
Are you perfect? As I showed, I’m not. I could crash my bike and cost the system a fortune. Where do we draw the line about lifestyle and create an I, Robot scenario where everyone is bubble-wrapped to maximize safety and life expectancy? Do we outlaw smoking, alcohol, motorcycles and guns too? While we’re at it, let’s ban Formula 1 racing, skydiving and surfing.
A friend of mine crashed his parasail last year and was seriously injured. He cost Canada’s healthcare system a lot of money. My only concern is that he recovers, not the public cost associated with his lifestyle.
You don’t need to concern yourself with the body weight of others. They’ve heard it all before. I wrote my Tribune article to dispel a myth that HAES has served to perpetuate and bring some clarity to lifestyle vs. abdominal obesity, as well as reveal the truth about the feasibility of sustainable weight loss, so that readers can use that bit of information to make their own decisions about their own lives. Beyond that, it’s a discussion for them to have with their family and their physician. And if they want my advice on healthier and leaner living, I will offer it.
Where Should HAES Go From Here?
Perhaps it should just go away, because it doesn’t appear to be helping.
It’s a flawed concept that is hamstrung as a movement by its very name. There is unfortunately no such thing as “health at every size.” And that’s one of the reasons why people are walking away from the movement. (Read that piece for disturbing insights).
We need a movement that focuses on being body positive without perpetuating bad science. It’s not just about obesity; there is plenty of shame to go around for every body type. We get bent out of shape about people being “too thin” or “too muscular” or having cellulite or acne or body hair or stained teeth … We’re telling the obese to put down the cheeseburger and the thin to eat a cheeseburger.
I just want to enjoy my cheeseburger and not have everyone spew so much hate and prejudice based on other people’s bodies and lifestyles.
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James S. Fell is an internationally syndicated fitness columnist for the Chicago Tribune and author of Lose it Right: A Brutally Honest 3-Stage Program to Help You Get Fit and Lose Weight Without Losing Your Mind, published by Random House Canada. He also interviews celebrities about their fitness stories for the Los Angeles Times, and is head fitness columnist for AskMen.com.
Body acceptance movement