Health at Any Size: Science Based or Wishful Thinking?

Posted: October 31, 2012 in Ask The Guyatitian, News, Uncategorized
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I have taken an unpopular stance amongst my peers that “health at any size” is simply a fantasy. We are in agreement on a few points, however: we need to focus more on achieving health and not about reaching a certain number on a scale. And regardless of size, everyone deserves to be treated with respect and dignity. That said, to think that you can be 350+ pounds and still be “healthy” is the exception, NOT the rule. In my nearly 30 years as a clinician, rarely do I see someone of “size” who has a healthy percent body fat, is absent of joint pain or metabolic health challenges and so on. By the way, I don’t see NBA/NFL players – that might be the exception to the rule though a great many x-athletes who maintain their size but not their activity are prone to the same aforementioned concerns.

This article featured in the Huffington Post, by David Katz, MD, does a great job in pointing out the flaws in the “Health at any size” philosophy. Of course, I would welcome your thoughts and comments!

Why I Can’t Quite Be Okay With ‘Okay at Any Size’
by David Katz, MD

There has long been a movement to defend the overweight from a prevailing lack of understanding. And, alas, that defense seems to be needed.

The evidence of obesity bias in our culture is abundant and pervasive, and can be found from playground to boardroom. We have historically done a poor job of attacking the problem of obesity without attacking those burdened by the problem of obesity.

The defense has come in the form of professionals who highlight the pernicious effects of bias. It has come in the form of organizations, such as NAAFA, the National Association to Advance Fat Acceptance. In my own case, it comes in the form of the National Exchange for Weight Loss Resistance, which I launched to help spread the word that some people can eat well, be active, and still never get to thin.

There has long been some okay-at-any-size support from Hollywood and Madison Avenue, as well. The Dove ads for women with “normal” curves are already classics. Oprah has emoted on the topic. Plus-size models can do quite well. And Queen Latifah has brought her inimitable “what you see is what you get, if you’re lucky” brand of gumption to the issue.

Apparently, though, we’ve entered a new stage of evolution on the topic. The New York Times recently reported that a whole new cadre of celebrities prone to the same obesigenic influences as the rest of us are simply shrugging their shoulders, and letting it all hang out. In some cases, quite literally — by exposing the expanding epidermis in question.

So “okay at any size” seems to be gathering pop culture momentum. And I regret to say, I can’t be entirely okay with that. It’s not the size I’m not okay with — it’s the consequences.

Epidemic obesity is not just a reason we have epidemic diabetes — it is the reason. It is the reason why the CDC is projecting that as many as 1 in 3 of us may be diabetic by mid-century, at a cost the nation is unlikely to find manageable.

It is the reason why what used to be “adult onset” diabetes is now a disease of children as well, and called “Type 2.” It is the known reason for a proliferation of ever more cardiac risk factors in ever younger people. It is the reason behind a triple coronary bypass in a 17-year-old boy whose case I know. And it is the likely reason for a 35 percent increase in the rate of stroke among 5-to 14-year-olds.

And the toll of this menace continues to rise. Not so much now because of more people becoming overweight, although that continues to happen. Rather, since most of us vulnerable to becoming overweight or obese are already there, the relevant trend at present is the degree of overweight, which is worsening fast. A recent report indicates that the prevalence of severe obesity has “skyrocketed” in the past decade. We can probably no longer gauge this epidemic by noting how many are overweight; we now need to monitor how overweight the many are.

These, then, are the stakes in play. It’s true that people can be fat and fit, but few of us are. More and more of us are fat to one degree or another, and most of us are unfit as well. These can be unbundled, but in the real world they seldom are. And when they are unbundled, it’s because thin people can be unfit, too. In general, the behaviors that cultivate genuine fitness offer the best defense we have against fatness.

And this points to a message residing more than skin deep. Whether fat or thin, what we eat matters. Food is the fuel that powers the human machine. It is the one and only construction material for the growing body of a child. It is the construction material on which adults rely to replace spent cells and enzymes and hormones every day. Junk is a poor choice all around, no matter your size.

And exercise matters. It is the vital, conditioning work of the body, whatever its proportions. The “okay at any size” message does not explicitly say that junk food and lounging on the couch are fine, but it doesn’t tend to say explicitly that they aren’t, either. We could be more okay at any size if we took good care of ourselves, large or small. But if one of the reasons for larger size is lesser attention to health, that’s not really okay. And frankly, what we know about prevailing dietary and physical activity patterns suggests that’s just what’s going on.

Along with helping many patients lose weight over the past 20 years, I have talked some out of the enterprise. I have told them they were healthy — and as far as I was concerned, looked great as well. I encouraged them to love the skin they were in, and not obsess for the rest of their lives with themselves 10 pounds lighter, or a size or two smaller. Sometimes they listened to this advice, sometimes not. Those that didn’t listen might well have benefited from a bit more cultural emphasis on the “okay at any size” message.

So I am not only okay with “okay at any size” up to a point, but an active proponent. I oppose obesity bias, and reject the notion that widespread obesity among children and adults alike is somehow due to an inexplicable, global outbreak of personal responsibility deficiency syndrome. If you have evidence of such an outbreak, it would be the first I’ve heard of it.

I am more than okay with the notion that weight and waist circumference do not measure human worth. I will gladly stand shoulder-to-shoulder with others inclined to fight in defense of this proposition.

I am not just okay, but adamant, that we should be able to attack the problem of obesity without attacking those dealing with the problem of obesity.

And I can be okay with “okay at any size” if it includes a proviso: okay at any size as long as health is not adversely affected.

But when weight imperils health, as it clearly does all too often, I am not okay with it. In this context, bold displays of burgeoning flesh, and “flab is fab” bravado may do more harm than good. We do not, as a society, want to normalize ill health or the factors that impose it. Fewer years in life, and less life in years is not an acceptable endowment to the next generation.

We could choose to give our children a future in which 80 percent of all chronic disease goes away, because we commit to making tobacco avoidance, eating well, and being active our cultural standard. Or we can be okay with the trajectory we are on, and give them ever more serious illness starting at ever younger age.

When the bigger we are on average, the harder and younger we fall victim to serious chronic disease, I am not okay with it — and don’t think anybody else should be, either. It’s not the size that inspires my opposition; it’s the consequences.

  1. BirthRD says:

    I think this author and HAES are talking about the same thing, just in a different way. While I do believe that “ok at any size” is true, the message is almost too simple and can be misconstrued an excuse to not pay attention to health. But it is an important idea to take apart the idea of “Fat=bad and Thin=good” paradigm. We are taught that if we are fat, that there is something automatically wrong with our health, and that if we are thin, we are automatically healthy, which is dangerous for everyone. It promotes the idea that fat people must to do whatever they can to get those numbers down on the scale, and for thin people to do nothing, when in reality it is EVERYONE who needs 60 minutes of physical activity a day, and EVERYONE who needs to eat their fruits & vegetables, and EVERYONE who needs to learn to listen to their body’s satiety cues to tell them when they’ve had enough to eat. The thing about messages is that we can’t control how people are going to construe them. We tell fat people to lose weight in a healthy way, they turn to low nutrient, low calorie foods, and starve themselves; and we tell thin people they are healthy because they have a BMI under 25 they are healthy, so they lounge on the couch and eat garbage. So its not that the HAES philosophy or message is a bad one, it, like many other message can be taken the wrong way. The whole point is that you can’t easily tell a person’s health by looking at how much fat is on their body. Only because we live a western lifestyle can you look at a 250 pound person and make a guess that they aren’t engaging in healthy habits, but you can likely do the same thing with someone who is just thin, but doesn’t look necessarily fit. But because of our prejudice against fat, we aren’t taught to make those kinds of judgements with fat and thin people.

    • guyatitian says:


      Thanks so much for your thoughtful response. Appearances can be deceiving, for sure…especially with “thin” people. I have clients who sport high percent body fat yet possess an appropriate BMI. You grab their arm and could swear they lost all of their muscle. You are so spot on in that we can’t get lost in the numbers on the scale or dependent on physical appearance as a barometer of health.

      We do need to be careful not to fall into the trap that someone who is skinny is doing all the right things and that someone who is overweight is doing everything wrong. We also fall into the trap that obesity is tied with some sort of character flaw. More research is supporting that the lack of sleep and stress exposure can also wreak havoc on our metabolism and spur us on to eat less nutritious and calorically dense foods, for example.

      That said, we are also experiencing an era of bizarre self mis-perceptions. A growing number of people under estimate their weight and of course, those with bonafide eating disorders often feel they are too fat. There is nothing wrong with being comfortable in your own skin and accepting of who you are – as long as you know who you are. We are all in agreement there. At the end of the day, we need to separate public health concerns from the need to be civil and respectful of ourselves and others.

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