I received an e-mail from reader Emma today who said that she had seen sources that said that obese people were at a higher risk for a number of health conditions and asked “are you and I at increased risk of that scary list of diseases and health conditions simply because we are overweight/obese?”

In order to understand the context of the research around fat and disease risk, it’s important to look at it from the lens of the current social climate and the confirmation bias that comes with it. Fear mongering around being fat is a national past time and researchers design studies from a bias about fat and fat people, and with the goal of proving things about fat and fat people, often funded by companies that profit from their findings. When we examine research around population groups and health we can’t do so without taking into account the stereotypes and prejudices of the culture in which they live. There’s also the issue that people are much less likely to read a piece like this than a statement like “the disease risks of obesity are well known.”

Let’s begin at the beginning. The statement that fat people are at a higher risk for some health conditions means that these conditions occur more often in fat people based on the current counts, it does not say that fat has been shown to cause these conditions. There are a number of things that can influence this.

The current counts can be biased. Imagine that I test brunettes for ingrown toenails early and often, and I never test those with other hair colors. Then I publish a report that just states that brunettes are at a higher risk for ingrown toenails. If you knew what my research methods were, you would scoff at my findings. But if you didn’t know, you might accept my conclusion that brunettes are at a higher risk for ingrown toenails, especially if the media picked up my report with headlines such as “Brunettes Ingrown Toenail Costs are Bankrupting the Nation.”

It sounds ridiculous but research about disease prevalence in fat populations that relies on reports of doctor’s diagnoses falls prey to exactly this issue. We don’t know anything about research until we know everything about their methods. Without a representative sample that controls for variables that could otherwise be confounding the research can’t even begin to claim to be conclusive. Doctors often test fat patients early and often for these diseases, even in the absence of any symptoms, testing thin people much less often. Some thin people have been misdiagnosed by doctors who believe that that diseases correlated with being fat aren’t possible for thin people, which leads to incorrect diagnoses for thin people as well.

But let’s say that these diseases do happen more often in fat people. There are still a number of issues with concluding that all fat people are at a higher risk, or that being fat causes the risk, or what can be done to mitigate it.

First of all, many conditions that cause the health problems have also been shown to cause weight gain – PCOS for example leads to weight gain and insulin resistance. There is a chicken and egg question that is very often ignored in the rush for headlines.

There is also the issue of access to medical care. In a study by Maroney and Golub called “Nurses’ attitudes toward obese persons and certain ethnic groups found that 31% of nurses said that would rather not treat obese patients, 24% said that obese patients “repulsed them” and 12% said that they prefer not to touch obese patients. Considering the fact that nurses are responsible for almost all day to day care in hospitalized patients and primary care in many clinics, their personal bigotry can interfere with fat people getting appropriate care (imagine how different your medical care might be if your nurse was actively trying to avoid touching you). In another study more than half of the 620 primary care doctors questioned described obese patients as “as awkward, unattractive, ugly, and non-compliant”. One-third of the sample further characterized obese patients as “weak-willed, sloppy, and lazy.”

Not only does this bigotry call the standard of care into question, but there are the many many reports from fat people (me included) having their actual health concerns ignored in favor of a diagnosis of fat and a prescription of weight loss. (My personal experience includes being prescribed weight loss for strep throat, a dislocated shoulder, and a broken toe.) Which means that fat people don’t get early interventions that may prevent the development of health issues later. Also, instead of being given interventions specific to health issues as thin people are, fat people are often given a generalized recommendation to change their body size. In some cases this may actually put them at higher risk for disease.

For example, if a thin person shows elevated blood glucose and a risk for diabetes they will be given lifestyle interventions to affect glucose levels and that risk. A fat person is much more likely to be told to attempt to become thin. If they attempt to do so by eating a low calorie, high carbohydrate diet and/or by waiting a long time between meals it can make their blood glucose numbers worse even if it results in short term weight loss. In this way the number of health incidences for fat people could actually be increased by following the advice of health care practitioners.

There’s also the issue of not being able to get adequate treatment because of inappropriately sized equipment. My partner had a knee injury and at a number of different appointment (including for x-rays and MRIs) the office didn’t have any armless chairs and she was told that she would just have to lean against the wall (in one case for almost an hour.) Everything from too-small blood pressure cuffs to too-small MRIs and CT scans cause us to get inaccurate test result, or preclude our being tested to begin with which can cause issues with early disease prevention and diagnosis, and could raise disease incidence rates.

There is also the fact that fat people live with a tremendous amount of shame, stigma and oppression in our society which have been shown in studies to be correlated with many of the same diseases as being fat. Further, campaigns that make fat people feel shame and hatred toward our bodies have been phenomenally successful, and in convincing us to hate and be ashamed of our bodies, they have also convinced many fat people that our bodies are unworthy of care.

Add to that the social stigma that comes with being fat and being diagnosed with one of these diseases, and the fat shaming and poor treatment that we can experience from healthcare professionals, and fat people can be much less likely to engage in our own healthcare. This spills over to many areas of health. Movement has been shown to have health benefits for many people of all sizes (though there are no guarantees and, of course, there is no obligation to engage in movement.) Yet stigma can also affect fat people’s ability to engage in movement – everything from the absence of appropriate workout clothing in our sizes, to people who moo at us and even throw eggs at us for simply being fat in public can create barriers to movement for fat people.

Finally, I think it’s important to remember that society in general, and some researchers and doctors and the media in specific, are content to state assumptions about fat people as if they are fact, which means that the research in the field is highly questionable for a number of reasons.

In short, there are no easy answers where this is concerned, and from my perspective there are way more questions than answers. But even if being fat puts us at greater risk for disease that doesn’t mean that if we could become thin we would reduce our risk (bald men are at a higher risk for heart disease but giving them hair plugs won’t prevent a heart attack.) We still wouldn’t know if the fat causes the disease risk or if the disease risk and the fat are caused by something else or are unrelated.To me the research is clear that, though there are no guarantees or obligations, healthy behaviors are our best chance for a health body regardless of our disease risk.

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