The public-health crusade of the moment is a no-holds-barred war on obesity. Those waging it donï¿½??t have time for subtlety. When Senator Christopher Dodd introduced the Obesity Prevention Act of 2008 this summer, he called obesity ï¿½??a medical emergency of hurricanelike proportionsï¿½?? that is wreaking havoc ï¿½??on our families, on our society and on our health care system.ï¿½??
But some activists and academics, part of a growing social movement known as fat acceptance, suggest that we rethink this war ï¿½?? as well as our definition of health itself. Fat-acceptance activists insist you canï¿½??t assume someone is unhealthy just because heï¿½??s fat, any more than you can assume someone is healthy just because heï¿½??s slim. (They deliberately use the word ï¿½??fatï¿½?? as a way to reclaim it, much the way some gay rights activists use the word ï¿½??queer.ï¿½??) Rather, they say, we should focus on health measurements that are more meaningful than numbers on a scale. This viewpoint received a boost in August when The Archives of Internal Medicine reported that fully half of overweight adults and one-third of the obese had normal blood pressure, cholesterol, triglycerides and blood sugar ï¿½?? indicating a normal risk for heart disease and diabetes, conditions supposedly caused by being fat.
This is a core argument of fat acceptance: that itï¿½??s possible to be healthy no matter how fat you are and that weight loss as a goal is futile, unnecessary and counterproductive ï¿½?? and that fatness is nobodyï¿½??s business but your own.
Many fat-acceptance activists prefer a new approach to dieting that focuses on nutrition, exercise and body image. A new book out this fall, ï¿½??Health at Every Size,ï¿½?? by Linda Bacon, a nutritionist and physiologist at the University of California at Davis, outlines this approach, which is less about dieting than a lifestyle change that emphasizes ï¿½??intuitive eatingï¿½??: listening to hunger signals, eating when youï¿½??re hungry, choosing nutritious food over junk. It encourages exercise, but for its emotional and physical benefits, not as a way to lose weight. It advocates tossing out the bathroom scale and loving your body no matter what it weighs.
The philosophy is migrating slowly into mainstream programs, like a spa in Vermont that focuses on ï¿½??acceptance of ourselves and our wonderful sizes.ï¿½?? But the spas and other programs have trouble with the bottom line of fat acceptance ï¿½?? rejection of weight loss as a goal. Weight Watchers, for instance, uses some of the same slogans, and while it promotes its program as ï¿½??not a diet,ï¿½?? it still tracks weight loss down to the decimal point.
Several studies suggest that if the aim is getting healthier rather than slimmer, then in the long run the ï¿½??Health at Every Sizeï¿½?? approach works better than dieting. In 2005, Bacon led the only randomized control trial to date that tested this hypothesis physiologically. She randomly assigned half of the 78 subjects, all women, to a ï¿½??Health at Every Sizeï¿½?? group; while they lost no weight, their healthier behavior led to lower blood-pressure and cholesterol levels, which stayed low even two years later. In the weight-loss group, more than 40 percent dropped out before the six-month low-calorie diet ended, and at the two-year follow-up, the average dieter had regained all her lost weight, and the only measurement that dropped was one for self-esteem.
Scientists who study obesity at the cellular level say genetics determines peopleï¿½??s natural weight range, right down to the type and amount of food they crave, how much they move and where they accumulate fat. Asking how someone got to be so fat is as meaningless as asking how he got to be so tall. ï¿½??The severely obese have some underlying genetic or metabolic difference weï¿½??re not smart enough to identify yet,ï¿½?? says Dr. Rudolph Leibel of Columbia University Medical Center. ï¿½??Itï¿½??s the same way that a 7-foot-tall basketball player is genetically different from me, at 5-foot-8.ï¿½??
Fat has been blamed for cardiac trouble, diabetes and some forms of cancer. But fat-acceptance activists argue that the epidemiological studies that link fatness to disease often fail to adjust for non-weight-related risk factors found more often in fat populations. Poverty, minority-group status, too much fast food, a sedentary lifestyle, lack of access to health insurance or to nonjudgmental medical care, the stress of self-loathing and being part of a stigmatized group ï¿½?? all are more common among fat people, and all are linked to poorer health outcomes at any weight. This makes it harder to say to what extent an association between obesity and disease is due to the fatness itself or to the risk factors that tend to go along with being fat.
It remains an open question, one deserving of further scientific scrutiny, whether the health risks seen in fat populations are caused by the fat itself or by something else. Only then can we really know how to effectively wage the war on obesity ï¿½?? or if such a war even needs to be waged.