Obesity (with Dr. Yoni Freedhoff)
What do we get wrong about weight? Where did BMI even come from? And is there really an obesity “epidemic”?
Today’s guest is Dr. Yoni Freedhoff, an Associate Professor of Family Medicine at the University of Ottawa and Medical Director of Ottawa’s Bariatric Medical Institute who’s known as Canada’s most outspoken obesity expert. He’s also the author of “The Diet Fix: Why Diets Fail and How to Make Yours Work.”
Citations and further reading:
- A History of Obesity, or How What Was Good Became Ugly and Then Bad by Garabed Eknoyan, Advances in Chronic Kidney Disease
- When Fat was in Fashion by Anne Hollander, The New York Times
- Fat phobia by Heather Ashbach, UCI News
- Same B.M.I., Very Different Beach Body by Albert Sun, The New York Times
- Why BMI is a flawed measure of body fat, explained by an eloquent 14-year-old by Julia Belluz, Vox
- Accuracy of current body mass index obesity classification for white, black and Hispanic reproductive-age women by Mahbubur Rahman, MD, PhD, MPH and Abbey B. Berenson, MD, MMS, Obstetrics & Gynecology
- The Bizarre and Racist History of the BMI by Aubrey Gordon, Elemental
- Anthropometry, Britannica.com
- Adolphe Quetelet and the Evolution of Body Mass Index (BMI) by Sylvia R. Karasu M.D., Psychology Today
- Indices of relative weight and obesity by Ancel Keys et. al., International Journal of Epidemiology
- Obesity epidemic increases dramatically in the United States: CDC director calls for national prevention effort, Centers for Disease Control and Prevention
- How Often Is B.M.I. Misleading? By Albert Sun, The New York Times
- Is dust making you fat? by Andrea Downey, The New York Post
- Low-fat vs. low-carb? Major study concludes: it doesn’t matter for weight loss by Michael Hull, Examine.com
- Fat Is Not the Problem—Fat Stigma Is by Linda Bacon and Amee Severson, Scientific American
- Airline Passenger of Size Policies: Will You Be Forced to Buy an Extra Seat? by Ed Hewitt
- How and why weight stigma drives the obesity ‘epidemic’ and harms health by A. Janet Tomiyama et. al., BMC Medicine
Suggest a taboo topic via firstname.lastname@example.org.
Visit tabooscience.show for more.
Taboo Science is written and produced by Ashley Hamer. Theme music by Danny Lopatka of DLC Music.
Ashley: We haven’t always been afraid of fat. It’s hard to remember that when you’re surrounded by diet products and fitstagram models and headlines about the latest one true way to lose weight fast. But this worry about gaining weight has only been around for a couple hundred years or so. Beyond some ancient Greek bros like Socrates, who talked about doing morning dance workouts to stay in shape, no joke, fat has historically been a good thing. Food was usually in short supply and hard labor was the norm for most people. So a curvy body indicated that you had what the masses didn’t: plenty of food and the money to pay someone to do your work for you. I mean, you’ve got your curvaceous goddess statues from the Pleistocene, the fleshy ladies in paintings from the Middle Ages, the thick figures of Michelangelo, Rubens, and Renoir.
Shakespeare wrote skinny characters as miserly and plump ones as jolly and good natured. And then, sometime around the 1800s, that all changed in the West. And like with many cultural changes, there’s no single explanation for why.
Maybe it was because life got easier, so weight became easier to gain. Maybe it came from religious influences that stressed temperance or from the newfound scientific understanding of nutrition and body thermodynamics. Some even say the newfound desire for thinness was a way for white society to differentiate themselves from black people. But whatever the reason, the cultural taste came before the medical concerns.
Whatever health effects do or don’t result from excess weight, you could argue that our culture’s fear of fat is more aesthetic than medical. We don’t do the same moralizing about cigarettes or bike helmets or death-defying Everest climbs as we do about obesity. And even if fat shaming did come out of a concern for people’s health, it would be wrong.
And I don’t just mean morally wrong. I mean I do, but I also mean it doesn’t do what you think it does. And I’m gonna tell you why.
I’m Ashley Hamer, and this is Taboo Science, the podcast that answers the questions you are not allowed to ask.
To dive into the science on this, I contacted someone I really admire for his no nonsense views on obesity.
Yoni Freedhoff: So I’m Yoi Friedhoff, and I’m an associate professor of Family Medicine at the University of Ottawa, and I’m the medical director of Ottawa’s Bariatric Medical Institute, as well as Constant Health.
Ashley: Seriously, every time I read an article about obesity, if Yoni Freedhoff is quoted in it, I figure the writer did their homework. So before I get into the basics of what obesity actually is, I want you to give it a shot yourself. What is obesity to you? Don’t worry about specific weights or measurements. I just want you to think about what you understand when someone talks about obesity.
Either in reference to an individual or in a general health sense. I want you to see how close your own understanding is to an obesity doctor’s definition. Here’s what Dr. Friedhoff said when I asked him to define obesity.
Yoni Freedhoff: So it depends on who you’re asking. Uh, so if you’re asking the late person on the street what obesity is, chances are they will think of a stereotype where the word itself is ascribed to characteristics and beliefs about, uh, the willpower or lack thereof of the individual, of their lifestyle and their habits and their choices. Uh, when you ask a physician about obesity and what it is, then they will perhaps give you a slightly better answer where they may refer to something called the body mass index, uh, which is your weight divided by your height in meters squared.
So it is basically a literal measure of bigness where looking at population-based statistics, uh, BMI beyond 30 has been described as, uh, a person who would have obesity. If you went a little bit further and asked somebody who was in the field of obesity medicine, especially more recently, there’s certainly been a move to change the definition some a bit further, where we would say a person has obesity, if their excess body fat, their excess adiposity was causing actual medical or psychosocial problems. And what that means is, is that regardless of your bigness or your weight, if your bigness or your weight is not causing any medical problems or psychosocial problems, then we would not ascribe the diagnosis of obesity to that individual. So I realize it’s a very long answer for a very, uh, easy sounding question, but that would be the best answer I could provide.
Ashley: So how close was that to the definition you had in your head? If you thought something about willpower or habits or choices? Well, I hope that by the end of this episode, your mind is a little bit changed.
Okay, so why is that layperson’s definition of obesity incorrect?
Yoni Freedhoff: So this idea that obesity is a disease of willpower or a disease of personal responsibility is quite prevalent.
I’d say that’s the most common view is that, oh, you just need to diet and exercise. Now, . it is true that through the use of forks and feet, you can change your weight. It’s true that weight is responsive to lifestyle changes. Those are truths. Um, it’s also true that you can buy low and sell high in the stock market and become a multimillionaire.
It’s true that if you just cheered up, you have less depression. So these aren’t useful truths. These are truisms, and I think that for sure when it comes to obesity, if simple desire were sufficient, we wouldn’t have this issue in society right now. If trying was sufficient, we wouldn’t have this issue because there’s no question that the vast majority of people who struggle with weight try to lose often dozens of times over the course of their lifetime.
Uh, marshaling more willpower towards weight management than anything else perhaps in their lives. And we know that if any amount of shame, blame, guilt, or fear drove behavior change, we would not have this issue in society because that is all we ever hear about obesity is some degree of shame, blame, guilt, or fear being foisted on people, including children.
Ashley: That’s not to say that eating less and exercising more is the wrong way to go if the aim is to lose weight. It’s just that it’s laughably, simplistic. And it’s also just dripping with moral judgment. There are a lot of health conditions that have seemingly simple fixes and yet affect hundreds of thousands of people, but those people aren’t mocked on television or bullied in the gym.
And all that stigma? It’s actually doing the opposite of what the bullies claim they’re trying to do, like I mentioned earlier. We’ll get back to that in a minute. But okay. What’s wrong with the physician definition of obesity? That all comes down to that handy little number known as BMI.
Yoni Freedhoff: Well, so BMI is just a measure of bigness. It measures how big you are. It measures your weight in relation to your height. It doesn’t do anything else. And it also is problematic because it is a one size fits all measure where one size does not fit all. So we know, for instance, that as we age, we will see our bodies change and that is a normal thing.
And so having this one BMI measure for all ages may be problematic. We know that different ethnicities see risks changing at lower weights or at higher weights. We know that BMI as a measure of just bigness doesn’t really differentiate between muscle mass and fat cells. And one of the examples a lot of people will turn to when we’re talking about the measure of bigness as a means to suggest someone does or doesn’t have health is to point out that, uh, over half I believe of the National Football League, the NFL, would be diagnosable on the basis of bigness as having obesity, but certainly over half of the NFL does not have any medical issues, uh, as a consequence. They are very fit healthy people, despite the fact that a scale says they weigh more than a particular table says that they should.
Ashley: In 2015, the New York Times published a striking illustration of how meaningless BMI can be on the individual level.
They showed 3D scans of six different men who were all five feet nine inches tall and 172 pounds. That’s 175 centimeters and 78 kilos. That puts them at a BMI of 25, which is in the overweight category. But their bodies looked nothing alike. One guy was trim and muscular. The next had a beer gut. Another was scrawny with a little extra around the middle.
How could they all weigh the same? It’s because fat isn’t everything. Muscle and bone contribute a lot to the number on the scale. But they’re denser than fat, so they don’t add as much to the body’s size. That’s why NFL players can register as having obesity.
But BMI doesn’t just identify problems that aren’t there. It can also miss problems that doctors should be concerned about. Like, say an aging patient who’s losing muscle mass and gaining fat, but staying at the same weight. And when it comes to BMI’s inaccuracies, race is a factor too.
Yoni Freedhoff: So for instance, East Asian people are much more likely to have to deal with, uh, uh, diabetes, uh, type two diabetes specifically, and problems with cholesterol.
And we see those associating with lower weights as risks. So whereas, we might say that diabetes risk starts increasing with BMI of 30 in Caucasians, uh, in East Asians it’s a lower number, more like 25. And so we do see this difference.
Ashley: Likewise, a 2011 study found that black women have a 3% lower body fat percentage on average than white women with an identical BMI.
That same study found that BMI alone failed to identify nearly half of the women whose body fat percentage met the criteria for obesity. Half!
This idea about BMI not actually working for people of different ethnicities is nothing new. It was known when BMI was invented in the early 19th century. BMI sprang from the mind of a Belgian academic named Adolphe Quetelet.
The same guy, by the way, who founded the field of human measurement known as anthropometry, which was eventually used by social scientists to quote, prove the superiority of whites over other races, and to identify criminals based on physical characteristics. Quetelet was out to identify “l’homme moyen,” the average man. Average, in his case, meaning ideal. To find the ideal weight he took measurements of the heights and weights of French and Scottish soldiers, so European men, plotted them on a bell curve and called the middle ideal. But he never meant it as a measure of build or fatness, or even as a way of measuring individual people.
Quetelet wasn’t a physician and neither were those who turned weight into a primary indicator of health in the early 20th century. Those were life insurance companies. They placed the heights and weights of their customers on actuarial tables and then used them to estimate life expectancy of prospective customers.
There was zero attempt at standardizing these tables. Every company did it differently. Some included age, some didn’t. Some included frame size, some didn’t. Some had doctors weigh people and others just used the honor system. But starting in the 1950s, physicians began to use those very insurance tables to judge the health of their patients.
Then in the 1970s, researchers led by Ansel Keys rediscovered Quetelet’s height-weight ratio. They compared it with other measurements of body fat at the time, concluded that it was superior, and renamed it body mass index, or BMI. That conclusion was based on their study of 7,500 men from five countries, most of them white, and even the participants from South Africa, the researchers noted, quote, “Could not be suggested to be a representative sample of Bantu men.” End quote.
The authors also hardly gave BMI a glowing review. They just concluded that it was better than the other measurements they had at their disposal, but it’s still only accounted for half of a person’s variation in body fatness. Nonetheless, in 1985, the National Institutes of Health officially revised their definition of obesity to be tied to a patient’s BMI, and in 1998, they lowered their cutoff of what actually constituted obesity.
Which put 25 million more Americans in the overweight or obese category overnight. That’s around the same time that the CDC announced that the US was suffering from an obesity epidemic, which some say is directly tied to that change in measurement.
But critics would argue that BMI is right most of the time — about 80% of the time, according to the CDC. It just isn’t a measurement that should have the last word.
Yoni Freedhoff: And so it, it really is a very crude statistic. It’s useful when you’re looking at populations of people, but it is not useful when you are looking at an individual, at the person sitting across from you or beside you in your medical office. BMI does not really add anything to the discussion that you should be having with that individual. Certainly, higher weights, and lower weights actually, so the extremes of BMI in both directions, the risks of various problems go up, but having a risk of something does not guarantee having the something, and I think that society and the medical profession has a bad habit of simply assuming that weight and health are synonymous with one another and, uh, as I’ve been saying, they certainly are not.
Ashley: So wait. It’s possible to have a lot of excess fat and not have health problems. Yeah, it totally is.
Yoni Freedhoff: Well, so there is no rule that states that a particular weight or adiposity confers problems. So scales, you know, the scales that we step on in our homes and in our doctor’s offices, they don’t and can’t measure the presence or absence of health.
So they measure the gravitational pull of the Earth at a given moment in time. Uh, what they don’t measure is anything else. And so just because a person has a specific weight does not mean that they are going to have medical problems nor that they are healthy. Because I’ve certainly met plenty of people whose weights would not meet the diagnostic criteria of obesity on the basis of that BMI table who live and are extremely unhealthy, both from a medical perspective and a lifestyle perspective, and vice versa. I’ve met plenty of people whose weights would suggest on a table that they have an issue, a medical problem, who are just fine.
Ashley: But let’s go back to that obesity epidemic. Like I said, critics claim that it’s really just a measurement problem. Are we really getting heavier or are we just defining obesity differently?
Yoni Freedhoff: We take a look at weight and its pattern over time. In every single country around the globe, it has risen very dramatically over the course of the past 60 or 70 years. There is literally not one country on the planet that hasn’t seen average weights rise in every single age category. From toddlers to people who are seniors, we are seeing weight rise. And as I was saying before, it is true that weight confers risk for a whole consequence of different conditions and issues.
And so when we see an entire population of a planet, gain weight over time and weight in turn increases the risk of various medical problems, yeah, I, I would say that there is a, a problem. You know, epidemic is a word that I think perhaps should be relegated to infectious diseases. We’re living through a pandemic right now.
There’s a lot of reasons for why we’ve seen changes with obesity, but unlike an actual epidemic, there is no one reason, right? So when we see what’s going on right now with COVID-19, it’s because of the SARS COV2 virus. We, there’s a one issue thing going on. That’s definitely not the case when it comes to obesity.
So I think language matters in the context of how people interpret and utilize that language. I’m not sure if epidemic is a helpful term. I’m actually not sure it’s a harmful term, but it’s something that I’ve not seen much work on. I’ve seen work on the diagnosis of obesity as a chronic disease where conferring a medical diagnosis and using terminology like chronic non-communicable disease actually decreases weight stigma among healthcare providers. That’s a good thing, not a bad thing. And certainly there’s been plenty of debates about whether or not obesity meets the criteria of diseases. Uh, I think it does.
So does the CDC and so does the Canadian Medical Association and various medical establishments around the world. I think it’s a discussion that’s a bit intellectual, not particularly useful.
But what we’re arguing right now is just about semantics. Has the world gained weight rapidly over the course of the past 60 or 70 years? Absolutely. Does it confer a risk? Absolutely. But does everybody who has X pounds on them have those conditions? Absolutely not.
Ashley: Okay, so what’s causing it? I mean, everywhere you turn, it seems like someone else has the one true answer. It’s processed food. It’s fat. It’s our sedentary lifestyles. It’s endocrine disrupting chemicals. It’s artificial sweeteners. It’s household dust. Seriously, that was the story going around a couple of years ago.
But as you might expect, the real answer as far as we know is complicated.
Yoni Freedhoff: So we know there’s at least 5,000 genes and 37 different hormones involved in weight management. So that’s at least, there’s probably more, but that’s a for sure. And that those genes and hormones were forged over millions of years of extreme dietary insecurity.
And those genes and hormones are very good at their job. And so we don’t yet have the ability in office to test people to see which ones they have. But suffice it to say we all have ancient genes and we are living in a very non ancient and fairly toxic food environment. When it comes to the availability of calories, they are now everywhere. So the number of calories that are actually being produced per capita per year has gone up dramatically over the course of the past 60 or 70 years due to farming practices and changes. We know that, uh, portion sizes have increased globally, so that has been a phenomenon that, you know, was born out of just consumerism and people trying to get people to come back to their restaurant that serves larger portions.
The food advertising dollars that are being spent are staggering. We’re talking about hundreds of billions of dollars globally per year on food advertising. Uh, we’re all the world’s best hunters now with Uber Eats. We can hunt from our sofa and order whatever we want and have large portions of things.
We have a food culture that’s broken. Where there is no event, too small to not warrant celebration with food, it would seem. And the types of foods we are eating has changed very dramatically where the percentage of foods that are ultra processed has gone up markedly and where the dollars we are spending on foods that we purchase outside the home has gone up markedly.
So basically the way society approaches food and the normal way society has approached food has changed. And so to sort of deal with food in a healthful way in our current society almost requires people to live abnormally compared to everybody around them. And that is a challenge that I think is unfair to foist on people.
And I think when we talk about, you know, could it be the environment versus the individual? One of the populations that we can look to really are the toddlers. You know, it’s not as if toddlers somehow have lost willpower over the course of the past 60 years of time, you know? And it’s also not likely that we have seen some kind of a medical problem or willpower loss that exists in every single country, in every single age group around an entire planet, all at once.
Ashley: There is so much confusion out there when it comes to weight. You can’t throw a rock without hitting three self-proclaimed nutrition experts giving conflicting advice. One says that animal fat is toxic, and you should focus on a plant-based diet full of greens and whole grains. Another says that the carbs in those whole grains will make you fat, and instead you should focus on a low carb, high fat diet. And the third says that it doesn’t matter what you eat as long as you stick to a certain number of calories every day.
And then there’s a whole other camp who says that losing weight is a losing proposition. 95% of diets fail, their story goes. Most people either fail to lose the weight or gain it back after some period of time.
If any other medical intervention had that kind of failure rate, it would be malpractice to recommend it. So why recommend diets? I asked Dr. Friedhoff about this.
(To Yoni Freedhoff) It seems like a lot of doctors recommend diets and it, and I, I’ve heard some statistic about how 99% of diets fail.
Yoni Freedhoff: It’s a silly statistic to be honest.
So, so I, I, that, that statistic is one that uses the wrong goalposts. And so, the example I would give in regard to dieting and failure, et cetera, would be running.
So I am a runner. I’m a, a very slow and not particularly gifted runner and have been that way my whole life. Now, if, let’s say, I decided that the only success story in running, would be qualifying for the Boston Marathon, which I’m 49, I believe that to qualify for Boston, I would need to run a marathon, a qualifying marathon in three hours and 15 minutes or less. Something along those lines. Let’s say that I decided that that was the measure of success and that I spent a year of my life trying to get there.
And let’s say I, I succeeded. I succeeded, but on the basis of really quite a miserable year in terms of running and long running and getting in fights with my wife because I wasn’t helping out with the kids and going to physiotherapy and eating foods that perhaps I didn’t enjoy and just really having a miserable time of it and I actually succeeded and I managed to get a qualifying time for Boston. I guarantee when I run Boston, you know, cuz the qualifying is the year before, I’m not gonna run it at the same speed. I’ll have slowed down because there’s no way I’m gonna be able to keep up that superhuman amount of training.
And I might justify it on the basis of, oh, you know, it was a hot day and I was stressed and whatever. But when the next year came around and it was time to consider qualifying again, cause you have to qualify every year, I probably wouldn’t bother trying cause it was such a, a misery the first time around.
Or alternatively, I might have spent that year of misery only to not qualify for Boston, which is the much more likely case scenario, and then just say, ah, screw it. I’m all done. I’m not gonna run anymore.
When it comes to that 99% of people fail, that’s trying to get people from sort of, again, this measure of bigness, this BMI table with a BMI over 30 to a BMI that’s so-called a healthy BMI of 23 and below.
And it’s true that probably 99% of people who try to lose weight and maintain a weight loss that brings them down into this so-called normal range is extremely low. May well be in the 1 to 5% range. So that would be, I think, similar to the number of people who are runners who actually qualify for Boston.
But when it comes to running, we aren’t so stupid is to think that the only thing that’s worth doing in running is qualifying for Boston, but for some reason this statistic keeps coming up in regard to weight management. If we look at different goalposts where a goalpost might be, for instance, maintaining, uh, weight loss that is sufficient to improve health, which would be in the neighborhood of 5%.
If we look to studies that have looked at people who are trying to lose weight and maintain it, we actually see really heartening results. So there was a study called the Look AHEAD Study. And the Look AHEAD study was, uh, designed to deal with reducing the risk of type 2 diabetes through intensive lifestyle change.
And when you look at the results from the Look AHEAD Study, eight years after the study, over half of the study group was maintaining weight losses of greater than 5%. And 27%, this is eight years later, were maintaining weight losses of greater than 10%. And that’s 10% of their presenting body weight. It’s really quite good.
And if we look at other studies, we, we see similar things where there’s plenty of people who maintain these lesser weight losses. These are people who are enjoying running, but they are not qualifying for Boston. And when you look at success, you need to have, you know, what is your goalpost, what is your marker for success?
And I think when we see people throw about that 95 to 99% of people fail number, they’re, they’re being disingenuous. Whether it’s on purpose or they just haven’t thought it through. Um, it really is akin to suggesting that, you know, nobody should run because very few people qualify for Boston.
Ashley: It’s also worth noting that even if 95% of diets fail, that means that 5% of diets succeed.
And according to researcher Kevin Bass, that’s actually a much better success record than a lot of medical interventions. Mammograms, prostate cancer screenings, blood pressure medications, and some diabetes medications reduce death by a lower percentage than that. But again, diets actually do lead to weight loss a lot more than 5% of the time.
And when it comes to those self-proclaimed nutrition experts, as long as they’re proposing that their diet is the one true answer, they’re just plain wrong.
Yoni Freedhoff: When we look at weight loss programs or studies or diet studies, what’s really quite remarkable is if you can get diet studies that have something called a waterfall graph.
Uh, so a waterfall graph would show the weight change of every single individual, um, in that particular weight loss study. And I’ll send, uh, an example of waterfall graphs over to you, uh, so that you might be able to include it in show notes.
Ashley: I did include it in the show notes. Just click on a link that says citations and you’ll see it as an image on that post.
Yoni Freedhoff: What’s amazing about waterfall graphs is that regardless of the approach, you know, whether it’s keto or low fat or intermittent fasting or whatever it is, there are people who do incredibly well. And people who do very poorly. Some people will lose dramatic amounts of weight. Some people will gain weight on every diet.
And so the biggest myth out there that I think gets in the way of people’s success is this idea that there is a best right way to go. It leads people to quit or to struggle. I think the idea that we need to be always on and that we need to be perfectly perfect all the time with our diets is problematic.
We accept imperfection and pretty much every other area of our lives, but people can have a weekend that is more indulgent than they had planned and have that throw them long term off of their goals. We don’t allow weight gain to exist mentally in our lives when we should. We’ll have good weeks and bad weeks in everything in life.
And again, we’re speaking about those people who are sufficiently privileged to prioritize this. But looking to those people, there needs to be room for imperfection and struggle. Because that’s life. Uh, going back to exercise as an analogy, cause I like it and it works. I’m still coming off of a back injury from the early winter.
I’m still regaining strength and endurance that I had before my injury. But what I did not do was stop exercising simply because I had a major setback. Just got back up and started again. But we don’t allow ourselves that permission when it comes to weight management and we should.
Ashley: Those myths are harmful.
No. But even if you question what this podcast has said about every single one of them, there’s one thing I hope you take away from this episode. Regardless of your weight or body type or views on dieting or whatever, it’s that shame and stigma do not work.
There are people I know and love who fully believe that they are helping by making rude comments about people with obesity. They think if it’s not socially acceptable to be fat, fat people will lose weight and improve their health.
First of all, other people’s health is not your business. But the other thing is no one is more aware that obesity isn’t socially acceptable than people with obesity.
They’re less likely to be hired, less likely to get a promotion and more likely to be paid less than their normal weight peers. They’re more likely to be denied access to medical care. They’re required to buy an extra airplane seat, and that’s only if there are two seats available. If there aren’t, they’re sometimes kicked off the flight.
And those are just the quantifiable statistics. They don’t take into account the routine interactions that remind them every day that, yeah, obesity isn’t socially acceptable. What’s even worse is that the bullies who tell themselves they’re well-meaning are actually achieving the opposite of what they claim to want. Weight stigma makes it harder to lose weight.
Yoni Freedhoff: Yeah. So not only does it appear to make it harder, but it actually might trigger maladaptive patterns of eating. It might lead people to be more likely to gain weight and to struggle. And it’s a strange thing that, again, we somehow think that for this particular issue, shame will be useful, but I think it’s been established over time that shame is not a great long-term motivator.
Ashley: In fact, a 2018 paper in BMC Medicine went so far as to say that weight stigma itself is actually helping to drive the so-called obesity epidemic. Studies have found that when people experience weight stigma, they eat more, their self-control weakens and they have increased levels of cortisol, a stress hormone that’s associated with weight gain. Weight stigma is also linked to a reduction in exercise, which is totally understandable.
Who among us hasn’t thought they needed to get in shape before they could join a gym? One study of 13,000 people found that people who reported experiencing weight discrimination had a 60% increased risk of dying independent of their BMI. That means it wasn’t their weight, it was the stigma. Weight stigma can literally lead people to an early grave.
Ugh. So how do we fix this?
Yoni Freedhoff: That goes back to what we were saying before about whether or not this is something that should be classified as a chronic disease. There’s less shame ascribed to people who have chronic illnesses. We were talking at the beginning about how this confers risk, but it doesn’t guarantee problems.
There’s many chronic diseases where there is a wide penetrance of how much it affects an individual. So for instance, I have asthma. But my asthma is very mild and exercise induced. And more specifically, actually, only if I’ve not been exercising for a while. And then there are people whose asthma is so severe that they end up multiple times a year in hospital, sometimes in the ICU, and some people die as a consequence of their asthma.
And then there’s everything in between those two places. And there are people who outgrow their asthma from childhood. And so I don’t think obesity is much different in that there’s different grades or degrees of obesity from almost inconsequential or nothing to very, very severe. And again, with most chronic conditions, we don’t simply, consequent to their being levers that people can use lifestyle-wise to affect change, we don’t judge them if they are not using those levers or if they’re not able to use those leaders.
There’s a tremendous amount of privilege involved in intentional behavior change in the name of Improving health, regardless of what that issue might be. You know that privilege, it’s obviously we all have the same number of hours in the day, but our hours are not all the same. And so people who are struggling with chronic medical conditions, who are struggling with caregiving responsibilities, financial strain, children with mental health issues, individuals with caregiving responsibilities for elderly parents who are, you know, struggling just to make ends meet. This idea that because weight has risk to it, they are going to marshal whatever mental energy they have left to prioritize healthy living over all else when we’re talking food, primarily. Where food absolutely plays a role for us in comfort, in, in pleasure, and should for everyone, regardless of their weight, it becomes very problematic.
I would, I would argue that it is a very, very small sliver of the population who truly possesses the privilege to be able to prioritize this as a very important thing in perpetuity. Because this is a chronic condition. If you stop treatment for a chronic condition, the condition comes back. And in Ottawa, my office, we have the fortune of being, uh, an office that administers Ministry of Health funded programs to people, meaning that people aren’t paying to come to see me, and 90% of our office is paid for by the Ministry of Health.
And so I meet people from a whole host of different backgrounds, and I can tell you that I’m not sure that I would be able, given the realities of many of these people, to marshal the resources they are marshaling despite all of the challenges they face, again, to try to focus on weight. And I think a lot of times, that notion of privilege being required and required in perpetuity is forgotten by the public and by the medical profession when they discuss the management of obesity,
Ashley: Our hours are not all the same. What someone does with their hours is no one’s business but their own. Same goes with their health. Just let people live in the bodies they have.
Thanks for listening. Taboo Science is written and produced by me, Ashley Hamer. The theme was by Danny Lopatka of DLC Music. And thank you so much to Yoni Friedhoff. If you want to hear more from him, you can check out his blog at Weightymatters.ca and follow him on Twitter @YoniFreedhoff. He’s also the author of the book, the Diet Fix, Why Diets Fail and How to Make Yours Work. You can find a link to pick that up and see everything else in the show notes.
Thank you to everyone who’s reviewed the show on Apple Podcasts and to everybody who follows the show on Instagram. Did you know that I draw stupid cartoons about the episodes and put them up on Instagram? They’re so stupid, but they make me laugh.
So like for the penis episode, I designed a bunch of dick pic texts from animals. You gotta see the duck. It’s great if I do say so myself. There wasn’t actually a cartoon for the cannibalism episode, but that cartoon was supposed to come out on Thanksgiving, and I didn’t wanna ruin your appetite with the news that the early settlers at Jamestown engaged in cannibalism.
I just did. Happy Thanksgiving. Anyway, you can expect the next episode in two weeks. Catch you later.