News of the coronavirus pandemic overshadows earlier concerns about our expanding waistlines. Becoming old and becoming fat increases our chances for dying from COVID-19. In What We Don’t Talk About When We Talk About Fat, Aubrey Gordon tells us to back off. Some fat people accept their fatness. They don’t want our condemnation, our advice, or even our concern. Unless asked for help, we should butt out. Other fat people wish to be thin again. How can we help those who wish it? Who or what should we blame for our fat nation? This month I look at possible sources of blame. This week I focus on fat people. In deference to Aubrey Gordon, I use the term fat rather than obese in this post. In the next two weeks I take on processed food and American culture.
Fat shaming. Deep down, most of us know that fat shaming or any other kind of shaming is not good. And yet, deep down, it’s hard not to pass judgement on fat people. News stories and medical statistics tell us that we are eating ourselves to death. It’s good to be thin and bad to be fat. Everybody knows that. Why don’t these people just stop eating so much as they get fatter every day? Why can’t they exercise a little control? All it takes is willpower. OK, maybe I am a little fatter than I should be, but I am not as fat as that person over there. What a shame!
No, fat shaming is not a good idea. Even if it was, fat shaming doesn’t really work. Fat people know that they are overweight by society standards. If they haven’t accepted their fatness like Aubrey Gordon, they are not happy with their weight. The more we shame them, the worse they feel. The worse they feel, the more insecure they become. The more insecure they become, the greater the pressure to eat. It becomes a downward cycle. Shaming is more likely to speed up that cycle than break it.
The causes of Americans becoming fat go beyond overeating. Studies show that there is a genetic predisposition to fatness. A person is more likely to become fat if one of their parents is fat. The chances increase if both parents are fat. When they grow up adopted children are similar in weight to their birth parents not that of their adoptive parents. Twins separated at birth grow up to be more similar in weight with each other than with their other siblings. Note, these are trends that don’t always hold. The studies suggest a strong genetic component to level of fatness. For additional information see Obesity 101 and In Defense of Processed Food.
Evidence indicates that a child develops a pattern of fatness early in life. Research suggests the ages two to five are critical in establishing eating patterns for life. A mother’s diet during pregnancy may even affect fat accumulation of her children. The set-point theory proposes that the body fixes the number or size of fat cells early in child development. Despite conscious attempts to remain thin, the cells call for more food. In light of these findings, it seems cruel to blame a fat person for behavior of their parents or caregivers.
Even so, research points to weight accumulation as a function of calorie accumulation. At its most fundamental level, after oxygen and water, calories are essential to life. Without them we waste away and die. Most nutritionists claim that a calorie is a calorie. Weight gain results from consuming more calories than we burn. Likewise, weight loss results from burning more calories than we use. Calories are burned in the body by one of three ways. The body burns calories to keep vital functions going. It takes energy to breathe, circulate blood, and digest food, and think. Exercise burns calories. Keeping warm in cold conditions also expends calories.
Many food journalists and self-taught nutritionists cry foul. Critics of the calorie-is-a-calorie meme separate weight gain or loss from the equation. Instead, they classify calories as good calories and bad calories. Good calories come from lean protein and fresh produce. Bad calories come from foods high in fat, starch, sugar, or a combination of these components. Think processed foods. Better yet, think ultra-processed foods.
The fastest way to become fat is to consume more calories than we burn. Eating too many low nutrient, energy dense (LNED) foods adds weight without nourishing our bodies. Many ultra-processed and homemade foods are high nutrient, energy dense foods (HNED). HNED foods provide nourishment but still add weight. Many weight-loss diets are effective. Despite the wide range of approaches, most diets are effective by restricting calories. Maintaining a restrictive diet over a long period of time becomes difficult. Too often, once the diet is over, the pounds come back. The weight after a rebound may be even higher than the original weight at the start of the diet.
We live in an environment that makes it difficult to reduce weight and keep it off. Too much food is available in supermarkets and restaurants. Don’t forget about the snack tray at meetings or the vending machine downstairs. Not only is there too much food, there is too much of the wrong kind of food be it LNED or HNED. We don’t spend enough time exercising which intrudes on our busy lives. And the heavier we get, the less inspired we are to work out. Even if we want to get more exercise our daily surroundings don’t encourage us. Many of us are not within walking distance to a supermarket. Even if we are that close, walking to the market is not safe for pedestrians. Bike trails are not accessible to many of us. Gym memberships and home-exercise equipment are expensive. Even if we are able to afford these luxuries, time to use them is hard to find.
The health risks of becoming too fat appear frequently on our screens. Gordon dismisses many of the health hazards of becoming fat. I took a dip into the scientific literature to find some answers. It was not a comprehensive view and was without intent to support a specific point of view. All the articles I found in this quick search emphasized severe health risks of being fat. Some caveats first. It is much easier to publish negative associations than positive ones. Almost all articles about processed foods are negative. Also, associations or correlations don’t prove causation. The relationships are not 100%. Not all fat people suffer these consequences even if many of them do.
Here is what I found viewing seven key review articles. Fatness is associated with breast cancer (1), diabetes (2,3), heart disease (4-6), metabolic syndrome (2), nonalcoholic fat liver disease (2), and severity of COVID-19 (4). Genetics, sex hormones, and age contribute to fat accumulation and distribution (6). The relationship between fat distribution and disease susceptibility is complex. The consequences of being fat may take a long time to become evident (7). A person may be fat and healthy for years before the toll catches up with them (6). Once a person becomes fat it is very difficult to lose 10% of body weight and keep it off (3). But, even a 5% weight loss can help prevent some consequences (7).
There are some situations where extra weight is beneficial. Moderately overweight people are able to withstand illness better than those of normal weight (5). This advantage is not clear in COVID-19 patients, however (4). In hospital settings overweight patients have a lower chance of death than very thin ones (7). They need the fat reserves to survive. Premenopausal women are less susceptible to breast cancer if fat. Postmenopausal women are more susceptible to breast cancer if overweight (1). BMI is the most frequent measure of fatness (5,7). Radiologic measure of subcutaneous fat is a much better indicator than BMI (6-7).
Health at every size emphasizes developing the healthiest lifestyle for every weight class. We cheer professional athletes who perform in oversized bodies. Many of them are in excellent physical shape during their careers. Once they stop performing, they may experience the difficulties of maintaining health without losing weight. Health at Every Size is a movement to achieve the best health one can achieve at a given size. We must move away from using weight or BMI as markers of good health. Careful monitoring of other measures of health such as blood lipids makes more sense.
I support Aubrey Gordon’s plea to end fat shaming and stop discrimination against fat people. We need to accept people as they are. If they ask for help, we should do our best to help. If they wish acceptance, we should accept them as they are. It may not be their fault. Many factors affect weight gain. The medical literature points to increasing chances for health problems as weight increases. Not every fat person is in health jeopardy, but many fat people are. Let’s stop blaming a person for being fat.
Next week: Blaming processed foods for obesity
References
(1) Hidayat, K., C.-M. Yang, and B.-M. Shi, 2018, Body fatness at a young age, body fatness gain and risk of breast cancer: Systematic review and meta-analysis of cohort studies. Obesity Reviews 19:254-268. https://doi:10.1111/obr.12627
(2) Cariou, B., C.D. Byrne, R. Loomba, and A.J. Sanyal, 2021, Nonalcoholic fatty liver disease as a metabolic disease in humans: A literature review. Diabetes Obesity Metabolism 23:1069-1083. https://doi:101111/dom.14322
(3) Mahat, R.K., N. Singh, M. Arora, and V. Rathore, 2019, Health risks and interventions in prediabetes: A review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 13:2803-2811. https://doi.org/10.1016/j.dsx.2019.07.041
(4) Petrakis, D., D. Margina, K. Tsarouhas, F. Tekos, M. Stan, D. Nikitovic, D. Kouretas, D.A. Spandidos, and A. Tsatsakis, 2020, Obesity—a risk factor for increased COVID-19 prevalence, severity and lethality (Review). Molecular and Medicine Reports 22:9-19. https://doi:10.3892/mmr.2020.11127
(5) Bosy-Westphal, A. and M.J. Müller, 2021, Diagnosis of obesity based on body composition-associated health risks—Time for a change in paradigm. Obesity Reviews 22(S2):e13190. https://doi.org/10.1111/obr.13190
(6) Frank, A.P., R. de Souza Santos, B.F. Palmer, and D.J. Clegg, 2019, Determinants of body fat distribution in humans may provide insight about obesity-related health risks. Journal of Lipid Research 60:1710-1719. https://10.1194/jlrR086975
(7) Zamboni, M., G. Mazzali, E. Zoico, T.B. Harris, J.B. Meigs, V. DiFancesco, F. Fantin, I. Bissoli, and O. Bosello, 2005, Health consequences of obesity in the elderly: a review of four unresolved questions. International Journal of Obesity 29: 1011-1029. https://doi:10.1038/sj.ijo0803005
In Defense of Processed Food 
Calories count. An inadequate supply leads to weight loss or worse. But for those of us who are adequately and over-fed, there are some important qualifications. Digestion is a four step process consisting of ingestion, breakdown (metabolism), absorption, and elimination. So you could say that counting calorie intake is just the beginning of a longer more complex process.
The most exciting new concept from my perspective to emerge out of current research on digestion is the concept of the food matrix. The term was originally used by food science researchers to explore, for example, the bioavailability of anthocyanins in purple carrots. Back in 2012, the USDA determined that certain factors could effect digestibility and alter the calorie count of almonds. The word matrix did not appear in this 2012 paper. However, what the researchers did determine is that, depending on whether almonds were eaten whole and how much they were chewed, the conventional calorie count for almonds was probably high. So yes calories count but if whole almonds are less calorie dense than almond butter, that calculation is not as straightforward as was originally thought. Research exploring connections between the concept of a food matrix and the degree of processing of a given food are current and ongoing.
Now what does the concept of a food matrix have to do with being fat or counting calories? All serious commentators on the current explosion of folks who are fat will say the same thing – the issue is complex and, since there’s no one single cause, there can be no single “silver bullet” solution. But what if the degree of processing has an impact on the body’s metabolism and results a greater rate of absorption? Industrial processing has been widely successful in offering choices which are easy to grab and fast to plate, but nothing comes for free. Eliminating ultra-processed foods is not going to solve the problem because the issue is complex. But I believe it’s worth exploring the extent to which ultra-processed foods contribute to weight gain.
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Excellent comments. You have been trying to get me interested in the food matrix as it affects digestion and calorie uptake. I concede your point. The matrix takes us away from the binary thinking of good calories/bad calories. Food scientists have studied the food matrix well before it appeared in the nutrition literature in 2012. The interest was in chewability. I agree that further research should tease out which ultra-processed foods are most likely to contribute to weight gain. Otherwise, the Twinkie and a bowl of All Bran cereal are equivalent as NOVA classifies both of them as ultra-processed foods.
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