11 May 2015

Deflating Fat Acceptance with more intelligent public health messaging

The Fat Acceptance (FA) movement has recently coalesced around a rejection of the mainstream scientific opinion on the health risks of obesity, as well as of the conception of obesity as a condition to be treated with diet and exercise. Meanwhile, the terms 'fat shaming' and 'thin privilege' have emerged to situate this public health conversation within a modern anti-oppression framework.

These developments coincide with a recent focus by health researchers and the media on 'the obesity epidemic'. Is this a coincidence? More importantly, can Fat Acceptance be deflated by more sensitive communication about obesity, and will this lead to improved health outcomes?

Fat Acceptance: a condensed history
FA has its roots in the fight against unfair attitudes towards the overweight fat people*. The movement originally fought against unfair associations (e.g., fat = lazy) and what they perceived to be a socially acceptable prejudice. It is this question of human rights that has largely motivated the National Association to Advance Fat Acceptance, the largest organization aligned with this movement, and this is the context of the movement described in the 1997 article by Lewis et al.

More recently, however, branches of  the second wave of FA have started to generate, recycle and promote more provocative claims, notably 1) fat ≠ unhealthy and 2) efforts at weight control are hopeless. These efforts are enabled by a mixture of solid evidence that most fat people fail to keep off any weight they do lose, human rights-based arguments that are associated to all anti-stigma campaigns and importantly, (what I see as) misleading conclusions about statistical associations. Critics argue that the FA message jeopardizes efforts to contain the well-established public health liabilities represented by obesity in a way that is reminiscent of the damage wrought by the anti-vaccine movement.

Public health, stigma and Fat Acceptance to the rescue (?)
By tying vulnerable groups to negative characteristics, public health can inadvertently create the conditions to isolate and devalue people on the basis of health. Modern FA has certainly seized on the stigmatizing reporting of obesity research, but by flat-out denying health liabilities of obesity, they short-circuit any prospect of gaining traction with mainstream researchers who study stigma, disease and public health messaging. I write about these dynamics here.

Health reporting is often offensive
When Richard Carmona said that obesity is a bigger threat than terrorism, he is right in a sense that the expected premature deaths currently understood to be caused by obesity vastly exceed those caused by terrorism, at least in the US. This evaluation might be useful to put different risks in perspective, but the connotations of this phrasing are offensive. Notably, obesity overwhelmingly affects the obese. The costs to society are indirect, obscure and somewhat academic. This is not the case for terrorism. Calling obesity more threatening than terrorism is inappropriately close to calling the obese more threatening than terrorists.

The term 'obesity epidemic' is in a CDC-sanctioned way of describing the rising rates of obesity and the associated secondary diseases that this is expected to cause. Insofar as obesity is a health status, this language is accurate. However, we should know that obesity (or fatness) has strong emotional, political and social dimensions and that by describing what is in many ways an identity as 'epidemic' is wrong.

It is on this basic point -- that the mainstream message is packaged in a moralizing, insensitive and unhelpful way -- that Fat Acceptance advocates builds a framework that rejects the broader public health advice to exercise weight control. Consider the below excerpt from the Shapely Prose FAQ. A red line runs under a paraphrased judgment intended to recall the offensive packaging of the public health message, and a green line runs under what is more or less its essence. By lumping them together, the author encourages us to view them in the same light.

Red = offensive packaging
Green = essence of the public health message
From overweight to fatness: our piece of the liberation cake
Fat Acceptance has thus evolved to situate obesity within modern identity politics, anchored by a community of activists who champion a liberationist mindset. To achieve symmetry with more mature branches of feminism, activists are logically compelled to recast obesity as an intrinsic property of the self rather than the product of lifestyle factors. Promotion of this paradigm is a very common feature of FA writing and activism. For instance, Lesley Kinzel, FA activist and author, writes in her book Two Whole Cakes that Michelle Obama is 'the biggest bully of them all' for targeting kids with her diet and exercise initiatives. Zeitgeist blogger Kate Harding writes that 'no one knows how to make a naturally thin person fat any more than they know how to make a naturally fat person thin'.

This reconception enables activists to frame medical advice on obesity as assaults on one's personhood and creates the conditions for 'alternative' [if I could make those quotation marks flash, I would] natural philosophies of health. 'Intuitive eating' and 'health at every size' (HAES) communities explicitly promote the idea that body weight is an intrinsic characteristic driven by 'natural' cues of hunger and satiety and reject the notion of weight loss as a health goal. In this framework, working to lose weight is working against the self and, supposedly, negatively affecting physical and mental health. But as sociologist Deborah Lupton writes:
'This discourse reproduces the classic Cartesian duality of the mind/self as separate from the body/flesh and turns it on its head. Instead of the rational mind positioned as superior to the fleshly body, here the body is represented as ‘wise’ and all-knowing, to which the mind/self should relinquish control. [...] But if nothing else, the sociology of the body and indeed, the sociology of food and eating (Lupton, 1996) have shown us motivations can never be fully or purely ‘internal’. They are experienced via social and cultural lens, including our own life experiences and our siting within the particular cultural context into which we were born and grew up.' 
In other words, claims that the body has 'natural' needs for a given regime of diet and exercise, and that these may be fulfilled with the offerings of a modern environment, are inconsistent with the status as humans as creatures of a constantly evolving society.

Behavioral obesity or innate fatness?
Reports on the failure of many people to achieve long-term weight loss results fit hand-in-glove with the notion that obesity -- or fatness -- is an intrinsic property of the self. For instance, Traci Mann, a [forgive the argumentum ad hominem] non-nutrition, non-health scientist who hypes the hopelessness of diet interventions in psychology journals, is something of a prophet to FA bloggers. It is true that most dieters (at least, those randomized to diets as an experimental intervention) regain a large fraction of weight they lost over a horizon of several years. Weight cycling is caused by changes in behavior. Failure to adhere to the lifestyle that accommodate weight loss leads to weight regain. The trivial observation that weight cycling is caused by changes in behavior is obfuscated by activists who hype the mantra of innate fatness, as if independent of lifestyle choices. For instance, Kate Harding asks, unironically, 'Why are we holding individuals responsible for the size of their bodies [...] ?' in connection with airlines' policies for passengers whose bodies are too wide for economy class seats.

The lifestyle basis of obesity is of course incontrovertible. Consider both the international differences in obesity prevalence (e.g., 10% in Norway vs. 35% in USA) and also the rising prevalence among rich countries (figure below and statistics from OECD). 

Physiological bases for obesity that are not amenable to lifestyle-based prevention strategies (e.g., leptin receptor deficiency) are exceedingly rare. Toschke et al. found that five risk factors (including watching more than one hour of television per day) account for half of childhood overweight and obesity cases. Weinsier observes that metabolic function has at most a very small effect on long-term weight gain and laments the conflation of genetic predisposition with deterministic fatalism.  

Where to go now?
All signs indicate that Fat Acceptance opinionmakers are motivated not by primary research -- indeed, they are silent on the majority of studies that link overweight to negative health outcomes and on the thermodynamics that link energy balance to obesity. Rather, their activism is systematically driven by the language in press coverage and by missteps in science translation. Activists however tend not to respond with measured criticism of this packaging but instead attack and misrepresent the fundamental science to support messaging in line with a body-positive worldview that abuts fecklessness.

Insofar as this process is enabled by reporting and communication that debases fat people, who are disproportionately economically and socially vulnerable, science communicators have an opportunity to preempt this dynamic. Bloggers can always deny science, but they will have a harder time convincing people when mainstream sources no longer come across as bullies.

A footnote on fatness
* To condense current thinking on the wrought identity politics of fat terminology: clinical words like 'overweight' and 'obese' imply a reference to some normative standard for body type in a way that, it is argued, is divorced from the social dynamics at the heart of the fat acceptance movement; the word 'fat' tackles these social attitudes directly. (Witness 'National Association to Advance Fat Acceptance', etc.)