Fat Chat

Walk up to a dozen people on the street, ask them if it’s unhealthy to be fat and most of them will say yes. Will being fat kill you? Undoubtedly. Should fat people lose weight? Absolutely.

It’s no surprise.

Anti-fat messages are ubiquitous. Across Canada, government policies, medical health professionals, public health campaigns and popular health articles – not to mention weight-loss businesses – are pushing the idea that fat is bad and if you’ve got too much, you’ve got to lose it.

Being fat is considered a disease all on its own.

In fact, the idea has taken hold that we are in the throes of a global obesity pandemic – sometimes referred to as “globesity” – and children are at such risk that immediate steps must be taken to save them from having shorter life spans than their parents.

One example: the Ontario government’s 2012 “No Time to Wait” anti-obesity strategy for children says that if nothing is done right now, as many as 70 per cent of today’s children will be overweight or obese by 2040, with severe impacts on health.

The implication? Canada is in a crisis of fat: obesity, whether among children or adults, is threatening the health of the nation.

Except, what if it’s not true?

Welcome to the world of Dennis Raphael, a professor in York University’s School of Health Policy and Management. He’s spent his career asking a lot of uncomfortable what-ifs like this one.

What if the mainstream story is not the real story? What if the real story is hidden from view?

The answers have led Raphael to become a global expert in the movement of analyzing the social determinants of health, or how living conditions affect your health.

“It’s almost unbelievable that obesity would not really be a big health problem,” he says in an interview from his Toronto home. But is it really the health epidemic it’s being called? Does being fat really harm you?

To find out, Raphael teamed up with two of his graduate students, Stella Medvedyuk and Ahmednur Ali, to examine the ideology embedded in Canada’s public policy on being fat, and whether that ideology is supported by current research.

The results of their study, published in 2017 in the journal Critical Public Health, are scathing.

It turns out there’s a mounting body of research showing that being fat does not shorten life.

Among the literature Raphael points to is a long-term study following 1.8 million people over a decade. It found that people considered overweight – measured by body mass index (BMI) – had the highest life expectancy, followed by those considered obese. The most short-lived were those with the least fat.

Not only that, but studies from many parts of the world – the United States, Denmark, Japan, Asia – found that carrying extra fat actually protects your health, whether you exercise or not.

 The dominant obesity narrative is based in fat hatred. We contend that the obesity discourse is itself the really dangerous epidemic 

In the scientific literature, this is called the “obesity paradox” because it’s so counterintuitive. Add in some physical fitness, and the links between fatness and any cause of death, including from cardiovascular disease, vanish.

“In summary, although having a body weight above the ‘healthy weight’ BMI category is said to result in poorer life expectancy, mortality, and morbidity, the evidence from the literature does not support this claim,” concludes a review paper by Lily O’Hara, a professor of public health at Abu Dhabi University, published earlier this year.

Not only that, but Raphael’s work also shows that the focus on eliminating obesity, while it aims to help people, can actually harm them. The shame of being fat tends to encourage fat people to cycle rapidly through weight loss and gain, a health risk. The stigma spawns fat prejudice, bad for psychological health.

Raphael points to work by Jennifer Brady of Mount Saint Vincent University in Halifax, and Natalie Beausoleil of Memorial University in St. John’s. They explain that the anti-obesity discourse running through Canada’s public health apparatus is creating a “moral panic” about being fat.

“The dominant obesity narrative is based in fat hatred,” they write. “We contend that the obesity discourse is itself the really dangerous epidemic.”

That distinction matters, Raphael says. Focusing on fat as a health crisis and giving people the idea that slimming down depends solely on their personal choices deflects attention away from the broader causes of ill health.

Among them: where you work, how reliable your work is, how safe your working conditions are, how much money you have, whether your housing is secure, your gender, whether you are disabled, whether you have secure access to good food, the cost of food and whether you are a member of a minority population group.

These are all the issues Raphael, who grew up in Brooklyn, N.Y., has spent decades exploring, fluently explaining his findings in a dozen books and hundreds of presentations, reports, newspaper columns and journal articles.

Addressing those systemic issues and trying to foster widespread equality would go a long way toward improving the health of Canadians, he says. One proof is the high levels of health among Scandinavians, who live in a more egalitarian society.

“[In Canada,] we’ll do everything to promote health except deal with the sources of ill health,” he says, adding, “No real determinant of health is getting better.”

In other words, governments are saying: eat your broccoli, but don’t expect a fairer society.

The one comfort is that questioning the mainstream fat narrative is catching on. Raphael’s surprised. While his work over time has been in high demand in Europe, here in Canada it has often been sidelined.

As former colleague David Coburn, now retired from the Dalla Lana School of Public Health at the University of Toronto, says, Raphael has made a career of speaking truth to power and has taken pains to let the public know what he’s found.

In fact, Raphael points out that his work is so countercultural that it took him 26 years to get a tenure-track position at a university.

“On this one – [obesity] – I’m lucky. It’s not just Dennis saying this,” he says. “People are a little more receptive because you can’t ignore it now.”

To wit: yet another critique of the mainstream fat narrative came out in July in the Journal of Obesity, this one taking on the 2016 Canadian Senate report on obesity. The paper by Angela Alberga of Concordia University in Montreal and others excoriates the Senate report’s “aggressive framing” and “disrespectful terminology” about obesity. Alberga recommends that future reports acknowledge the diversity of healthy body shapes in society and give a nod to the risks of stigmatizing fat. She also asks that ongoing research takes into account the social determinants of health that Raphael has spent so much time explaining.

That’s not to say everyone agrees with Raphael on the fat front.

Many well-meaning physicians and public-health advocates are still urging people to lose weight for the sake of their health. Raphael gives a hearty nod to their genuine wish to help people.

But the inconvenient truth is that it’s not working. And it won’t work. In fact, it’s doing more harm than good.

Raphael’s prescription? Abandon the effort. Focus instead on improving the conditions of life. That’s where policy could really make things better.