10 things I've learned this year about "obesity".

In the beginner's mind, there are many possibilities, but in the expert's mind, there are few. -Shunryu Suzuki

This morning, I listened to a Radiolab podcast episode about the discovery of the interstitium, an organ that wasn't so much recently discovered as recently acknowledged as existing. The episode ended with the above quote and a reflection from the featured pathologist who said, about the quote in relation to this story, "It's so profound. What had I been taught that got in the way? What am I missing now?"

This reflection struck me as exactly how I feel about all that I've learned this past year about BMI, obesity, the "obesity epidemic", anti-fat bias and discrimination, body autonomy, and our relationship with food as a society. In particular, it struck me as the exact question we should all be asking, but especially those in the health and health-adjacent sectors who now wield so much power over peoples' access to information, treatment, dignity, and health outcomes as they relate to weight and food.

If you've read this far and are perplexed by what I mean, let me share a short sample of the many things I've learned about these topics this year:

1. The BMI was developed using data from French and Scottish (read: white) male military conscripts close to 200 years ago. It therefore is based on no data about women (and certainly none about gender non-binary or transgender folks) or people of any other ethnic background.
2. The difference in mortality among people in the "Overweight" and "Obese" categories of the BMI and people in the "Normal" weight category is actually statistically insignificant. Furthermore, mortality among people in the "Underweight" category is higher than those in the "Overweight" or "Obese" categories. Yes, that means weighing too little is actually more indicative of potential mortality than weighing too much.
3. Over the course of the past few decades when the "obesity epidemic" supposedly began and escalated, the actual definition of BMI categories has shifted multiple times. In fact, on one day in 1995, thousands of people went from being "Normal" to "Overweight" overnight without gaining a pound.
4. Around the time that definitions were shifted to include many more people in the "Overweight" and "Obese" categories, drug companies like Pfizer, Roche and Abbott were actively developing weight-loss drugs. These drugs were only reimbursable by health insurance for people considered to be in higher BMI categories. Also, The American Obesity Association is funded largely by companies that benefit from the catastrophization of fatness-- WeightWatchers, Slimfast, Jenny Craig, Roche, etc.
5. A shocking number of studies about weight rely on self-reporting. What isn't shocking is that people are more likely to under-report their weight than to over-report it, especially when asked to report not only on what they currently weigh but what they weighted 5, 10, or 20 years ago.
6. Most diets don't work, and most people who try to lose weight gain the weight back plus more eventually. In other words, "eating healthier and exercising more" is a statistically ineffective strategy for reducing body weight long-term.
7. While it may be true that, on average, heavier people have higher cholesterol and/or blood pressure than lighter-weight people, it's also the case that heavier people have lower cholesterol and/or blood pressure than lighter-weight people did a few decades ago.
8. A large portion of the studies linking weight to other diseases like diabetes and heart disease show a correlation, but not necessarily a causation. In other words, we don't actually know that excess adipose tissue causes diabetes or if a predisposition for diabetes also means a predisposition for having more adipose tissue.
9. People (especially women or female-identifying people) with higher BMIs tend to avoid seeking healthcare for longer than people with lower BMIs. And they're not imagining weight stigma in healthcare: in at least one survey, the majority of medical students were found to have both explicit and implicit anti-fat bias that impacted how they would treat an "overweight" patient.
10. As with so, so many things, systemic, structural and individual racism is intrinsically and extensively linked to weight stigma and anti-fat bias.

These, and so many more tidbits, have led me to the conclusion that we neither know enough nor are asking the right questions about these topics.

Ask yourself:

• Do we know how many statistics we're relying on that are based on surveys asking people to accurately recall and report their weight yesterday, 5 years ago, or 20 years ago?
• Are we actually thinking about the difference in health metrics not only between people of different weights today but between people of all sizes today and people of all sizes 50 years ago?
• Are we paying enough attention to who is financially supporting and benefitting from the research and associated public outcry about fatness?
• Do we care enough about the other consequences of anti-fatness, like lack of access to adequate healthcare, detrimental impacts of weight cycling, and mental health conditions?
• Are we talking enough about the potential increase in disordered eating and self-harm resulting from anti-fat bias and what the health outcomes of those experiences and conditions are?
• Do we have any idea if being stressed about access to food or the number on the scale is more or less problematic than the weight itself?

We're not asking enough of the right questions.

I've primarily worked in health care and social services for the past few years and have been delighted to see a surge in creative and innovative work focused on increasing access to food for people without it across the country. But I have also been dismayed by how much of this work is purportedly "to address the obesity epidemic" or "to prevent obesity." Food and nutrition security is not and should not be synonymous with weight control. Body weight changes should not be the metric by which we measure the success of programs that enable our neighbors to access and eat whatever food they want, whether that's an apple or a piece of fried chicken. Employers should not reward employees for losing weight simply because the expensive health insurance plans they pay for say they should.

We must stop acting like experts for whom there is only the one answer of weight loss to solve for a myriad of complex conditions and realities. There are actually many possibilities.

As you think about kicking off 2024, may I suggest a reflection question:

What have you been taught that has gotten in the way? What are you missing now?

Special thanks to Aubrey Gordon and Michael Hobbes of my favorite podcast, Maintenance Phase; Abbie Atwood , Katherine Flegal, Sonya Renee Taylor, and many others who taught me so much.

A non-exhaustive list of sources and resources:

• Obesity: An overblown epidemic? (Scientific American, 2006)
• Medicare's search for effective obesity treatments: diets are not the answer (American Journal of Psychology, 2007)
• Historical Review of Extra Body Weight Definitions (Journal of Obesity, 2016)
• The Racist Roots of Fighting Obesity (Scientific American, 2020)
• You Just Need to Lose Weight and 19 other myths about fat people by Aubrey Gordon