medicalizing someone at a higher weight opens up more opportunities to sell them weight-loss/health products! Actually, 77% of the NIH Obesity Task Force were weight-loss clinic directors,7 and the majority had multiple industryrelated conflicts of interest.8 Yes, our country is getting heavier as the decades go by. Agreed — this is undeniable. There are many correlations with this increase, but we have all learned that correlation does not prove causation. We cannot prove a specific cause that lets every diet-plan sect blame their forbidden fruit of choice. We need to stop blaming individuals for our society’s changing body types. We ignore studies that show people at higher weight were more likely to have been infected with adenovirus-36 and that infecting multiple animal species with this virus led to increased weight gain and body fat without changes in their caloric intake.9,10 We also ignore the true magnitude of the “obesity epidemic.” The CDC published in JAMA that “more than 400,000 Americans died of overweight and obesity every year, so many that it may soon surpass smoking as the leading cause of preventable death.”11 The retraction, which was far less publicized, acknowledged that there were computational errors in the original study, so that “obesity and overweight were only associated with an excess of 26,000 annual deaths, far fewer than guns, alcohol, or car crashes.” In 2000, there were 86,000 fewer deaths than expected of people in the “overweight” category than if they were at a “normal BMI.” Furthermore, there were slightly more total deaths of people in the “Underweight BMI” category than those in both the “overweight” and “obese” categories.12 When we continue to blame the individual for a problem that is not completely a problem, we ignore the influences of social determinants of health, of racism, of misogyny. Just like healthcare institutions want to pretend that the individual physician who is burned out was not “resilient” enough rather than having to address systemic burdens, we also pretend that a person at a higher weight is “lazy” or doesn’t have enough willpower. Studies show that people at higher weights consume approximately the same amount or even fewer calories than lean people.13-16 The myth of “calories in, calories out” is just that — a myth. Diets don’t work. It has been proven repeatedly that calorie restriction leads to higher weight rebound eventually,17-23 but the $5 billion health/ wellness industry has a very vested interest in convincing us that “this one” will be the unicorn magic pill/diet/ whatever that changes your life forever. Or you can change your life forever by choosing to opt out of the diet mentality and get off that hamster wheel. Marketing machines don’t make any money with this approach because the opportunity to capitalize on the latest fad/gimmick/or program is eliminated. Naomi Wolf says, “A culture fixated on female thinness is not an obsession about female beauty, but an obsession about female obedience. Dieting is the most potent political sedative in women’s history; a quietly mad population is a tractable one.”24 Enter Health at Every Size.25,26 Lindo Bacon, Ph.D., collated the studies in their groundbreaking book of the same name. They demonstrate that every body has a natural weight setpoint, even if it doesn’t align with our current guidelines as “healthy.”27 The body wants to return to that weight, regardless of what we eat/exercise.28 But if someone cannot control/ lower their weight setpoint, then they should not be blamed as “lazy” or “noncompliant.” The next step is this radical concept: treat people without regard for their body size. Treat their medical conditions like diabetes and hypertension, certainly. But: • Stop denying needed medical care (such as surgery or medication) until they lose weight. • Stop encouraging weight loss since studies have shown repeatedly that diets don’t work. • Recognize that we all deserve to take up space in this world — no one expects a Great Dane to look like or fit into a carrier intended for a chihuahua. • Stop asking people to change their natural body characteristics because it makes others feel more comfortable. • Start treating all people as human beings worthy of genuine care. Because we all are. All bodies are good bodies, regardless of size, gender identity, race, level of disability, social status or any other method society has created to put people into boxes. Michigan is the only U.S. state that explicitly forbids fat discrimination.29 There is a very real benefit to being thin in this society: Fat people make less money than thin people.30 They are the subject of frequent micro- and macroaggressions. They are judged as “lazy” and “less than.” The prevalence of weight-based discrimination is now as common or more so than race- or gender-based discrimination.31-33 Is it any wonder that 30 million Americans are estimated to have an eating disorder in their lifetimes? Again, we need to stop blaming the individual for a systemic problem. What can we do as family physicians? Make clinic visits more accessible: • Wider seats in all areas (so that all your patients and staff are comfortable) • Seating available that has no armrests • Sufficient weight limits on equipment Reduce patient anxiety about clinic visits: • Being weighed is a choice, except for when absolutely necessary (eg, weight-based dosing of a medication or e-prescribing for someone under 18) • Don’t mention losing weight unless someone asks about it • Don’t congratulate someone on weight loss — you don’t know what they went through to get there • Treat them for their chief concern, not for their weight • Remove “well-nourished” or mentions of BMI/weight-based terms from your physical exam template. People at a higher weight cringe when reading their notes because these terms | 24
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