A Different Perspective on Weight, COVID, and Health

From very early on in the pandemic the rhetoric about COVID weight gain and the impact of body weight on risk for COVID ramped up. This response isn’t new. Body weight and higher BMIs are commonly blamed for a wide array of illnesses and disease states. The popular belief is that any diagnosis a person might have can be cured by simply losing weight.

So it only makes sense that global pandemics would be thrown in with that too, right? Or does it? (If you have been keeping up over the past year there have been many so-called cures and associations for COVID that have been made along the way that have been disproven. Hydroxychloroquine anyone?) Higher body weight has been touted as a widely accepted risk factor for the virus, but the real truth is that weight and BMI are an easy target in our society and the information that is shared in the media, social media and the in recommendations around weight and health are flawed, unhelpful and ultimately do more harm than good.

I hear the deeply emotional personal stories from clients all the time about seeking medical care and being told, no matter the issue, to “just lose weight.” I often sit and listen to clients and their experiences with mouth agape and head shaking in disbelief. One client just recently told me about hurting her knee years ago, going to the doctor, being told to lose weight and receiving no further treatment such as an MRI to rule out a tear or serious issue. Turns out she did have a tear that with treatment and/or surgery might have been resolved, but instead, now years later, she is still dealing with pain and mobility issues as a result. This is just one of many experiences like this that I hear about weekly in my conversations with clients, family, and friends. (Read more accounts here and here.) These aren’t just stories, the research also shows that, while sometimes unintentional, weight bias and anti-fat attitudes are pervasive in our society.

Weight Stigma & Bias

Sadly, in our society, it is socially acceptable to shame, judge, and stigmatize people based on their weight and size and shape of their body. Although, it is still a major work in progress, there is rising awareness that weight stigma is a serious problem and that the impacts of it are wide reaching. The negative assumptions we make based on weight impact both the mental and physical well-being and health of people in not only in larger bodies, but people in bodies of all shapes and sizes.

If you aren’t familiar with the term, weight stigma is defined as discrimination, social disapproval, or stereotyping based on a person’s weight or body size. Weight stigma is a direct outcome of weight bias in our culture, which is the negative assumptions, opinions, and stereotypes associated with weight. Weight stigma and bias are widespread in our culture existing in our schools, workplaces, and in healthcare.

“The key isn’t to feel guilty about our biases – guilt tends toward inaction. It’s to become consciously aware of them…”

We all have biases, some we are conscious of (explicit biases) and others exist more unconsciously (implicit biases). In an article titled, Bias Is Universal. Awareness Can Assure Justice, in the New York Times, Neill Franklin made this insightful comment, “The key isn’t to feel guilty about our biases – guilt tends toward inaction. It’s to become consciously aware of them, minimize them to the greatest extent possible, and constantly check in with ourselves to ensure we are acting based on a rational assessment of the situation rather than on stereotypes and prejudice.” Although his comment was regarding racial biases, this same ideology can be applied to the biases we hold around people in larger bodies.

A systematic review of 33 studies on weight stigma and the psychological and physiological health outcomes in adults found that weight stigma was associated with increased:

  • diabetes risk
  • cortisol level (the stress hormone)
  • oxidative stress level
  • C-reactive protein level (a measure of inflammation)
  • eating disturbances
  • depression
  • anxiety
  • and negative self-esteem and body image.

Ultimately weight stigma and anti-fat bias promotes the very thing we are trying to prevent, leading to weight gain and poorer physical and psychological health. When we recommend weight loss, make negative comments about people’s bodies, “concern troll” by expressing concern about people’s health in larger bodies, or provide healthcare that is any different than what we provide a person in a smaller body we are actually harming their health, not helping.

COVID and Weight

To believe the headlines, is to believe that it is an unarguable fact that if you exist in a larger body and are “obese” then your risk is greater in regards to COVID and severe outcomes from the virus. In reality, it’s way too early to make sweeping judgements about COVID and weight and studies at this point are preliminary and results are mixed. It is important to note whether the reports to date controlled for race, socioeconomic status, quality of care, or individual health risks that may worsen outcomes of the virus – all important confounding variables and social determinants of health that could explain some of the outcomes. Some have controlled for some of these factors and others haven’t. Because of our overarching societal belief that fat is bad, we are primed and ready to accept without question the headlines around COVID and weight.

Although we see headlines all the time about the results of studies that support the idea that higher BMI and higher weight put people at increased risk, we don’t hear as much about the research that shows the opposite. In fact, two recent studies showed that people in larger bodies and at higher BMIs are NOT at increased risk. One study out of Madrid including over 2,000 people found that higher weight people DID NOT have any greater risk of dying than lower weight people. The other, as published in the International Journal of Obesity, titled “A higher BMI is not associated with a different immune response and disease course in critically ill COVID-19 patients” found that, “in COVID-19 patients requiring mechanical ventilation in the ICU, a higher BMI is not related to a different immunological response, unfavorable mechanics, or impaired outcome.”

Some of the noted differences found in studies regarding COVID risk and higher BMI may also be a result of weight bias and later initiation of treatment for larger-bodied people. We have seen a similar scenario before with the H1N1, or swine flu, back in 2009. With that outbreak preliminary studies showed a link between “obesity” and “overweight” initially but with further closer review they found that after adjusting for early antiviral treatment that the “relationship between obesity and poor outcomes disappeared.” The important variable that changed the outcome was the finding that smaller-bodied H1N1 patients were more likely to get early antiviral treatment, resulting in better outcomes.

“Disentangling contributing factors and comorbidities is difficult but critical in order to make any definitive statements about the risks or causes of any illness, including COVID.”

What we know at this point is that some studies are finding an association or correlation between having a high BMI, particularly BMIs over 40, and being at increased risk for hospitalization and severe COVID-19 symptoms. But, just because there is an association does not mean that one causes the other. Correlation does not mean causation is a basic tenet of research and statistics, but is one that is often ignored when it comes to studies and information around weight and health risk, whether regarding COVID or all the many other disease states blamed on body weight. It is a common belief that being in a larger body increases risk for chronic diseases like heart disease and diabetes, but people in smaller bodies get these diseases too. There is no doubt there is an association between higher weights and certain medical conditions, but although it goes against our core beliefs, ultimately in assuming a causal relationship we fail to recognize the intricacies of the issue.

“The associations between weight and health are complex and by simplifying it into thin=healthy, fat=unhealthy, we are ignoring the complexity and missing the mark.”

Disentangling contributing factors and comorbidities is difficult but critical in order to make any definitive statements about the risks or causes of any illness, including COVID. At this point it is too early on and researchers don’t yet have a full understanding and enough conclusive evidence that the fat on a person’s body, or their ratio of height to weight or BMI, is to blame. The associations between weight and health are complex and by simplifying it into “thin=healthy, fat=unhealthy,” we are ignoring the complexity and missing the mark.

The Things We Say and How We Say Them Matter

In a recent article written by a fellow dietitian about COVID and weight, it was suggested that at this point in time doctors need to be not only talking with patients who qualify as “overweight” or “obese” about their weight, but also anyone else who may be what is deemed a “healthy” weight but has gained weight over the past year during the pandemic. I highly disagree with this recommendation. People who have gained weight over the last year, or ever for that matter, are fully aware of it and don’t need a doctor or anyone else to point that out to them. The question to ponder is would we express the same concern to someone who has lost a noticeable amount of weight due to the stress and strain of this difficult past year? In our diet and thin-focused culture the answer is usually no.

It can also be helpful to think about how we refer to people’s bodies and their size and weight as medical professionals, in the media, and in common lay conversations. When we categorize people and label them, such as with terms like “obese”, “obesity” and even “overweight” (terms largely based on the very flawed, outdated, and problematic calculations of BMI, read more about that here) what the research bares out is that isn’t helpful and ultimately reinforces the negative impact of weight stigma, reduces the motivation for weight loss, and potentially leads to avoidance of future medical appointments.

It is critical that we, as a group, including the media, medical professionals, and anyone discussing the topic of weight and health are mindful of how we talk about it. Multiple studies have found that simply reading a news article about the so-called “obesity epidemic” induces weight stigma and anti-fat attitudes among participants, causing harm, not helping.

There are so many MUCH larger problems to contend with that have come from everything we collectively have been through over the last year without further adding fuel to the fire by shaming people for their weight or size and shape of their bodies. It is not only NOT helpful, but is deeply harmful. The scientific evidence on this subject is very clear, criticizing and calling people out for their weight, body size or eating behaviors is not motivational and does not result in weight loss. We just simply can’t shame people thin.

What We Can Do Instead

An alternative approach if a doctor or other health professional or friend or loved one is concerned about someone’s health would be to ask them first for their consent in the conversation and then to ask meaningful questions about how they have cared for themselves and how they have been doing mentally and emotionally over this difficult past year. The answer is not to further judge and stigmatize people about their weight or insist for all people in larger bodies to just become smaller (talk to any person living in a larger body and see how simple that is.) Shame is not the answer. So what is?

“Treat all people with compassion, basic human decency, and respect and focus on behaviors, not weight.”

Treat all people with compassion, basic human decency, and respect and focus on behaviors, not weight. I may sound like a broken record at this point for those of you who read my blogs regularly, but if your goal is health or as a health professional if your goal is to help people be not only physically more healthy, but also mentally and emotionally, a focus on behaviors versus weight is far more beneficial.

As medical professionals, the goal should be to give the same treatment to people in larger bodies that we would give people in smaller bodies. The best way to provide ethically sound healthcare is for medical professionals, doctors, nurses, dietitians etc. to avoid making assumptions and basing their treatment/recommendations on weight or body size and shape.

For instance, if a patient comes in with a complaint of knee pain instead of just telling someone in a larger body to lose weight, give that person the very same treatment you would someone in a smaller, thin body, whether that is anti-inflammatories, further tests like an MRI to rule out serious issues or possibly physical therapy. Far too often patients, no matter their complaint or problem are given a diet or told that they must lose weight before they can be treated. Using the knee problem again as an example, what happens is that the patient goes untreated, the problem worsens, and then when patients muster up the guts to come back in for help the worsening of the problem is seen as a weight issue instead of being a lack of treatment early enough issue.

“Despite popular belief, when we look at the evidence, there is no scientifically proven way for the majority of people to lose weight and keep it off long term.”

The advice of “lose weight” isn’t helpful for most people. Despite popular belief, when we look at the evidence, there is no scientifically proven way for the majority of people to lose weight and keep it off long term. When you look at the data of any intentional weight loss intervention at the 2-5 year mark the failure rate (not of the people doing them, but of the diets/interventions themselves) is dismal. So is it really ethical to promote weight loss as a solution? Or would it be more ethically sound to focus on behaviors and habits people can actually do to take care of themselves?

People are so much more than just bodies and the number on the scale or a BMI calculation. We are individuals, not statistics or categorizations based on an archaic measure. While the intentions behind prescribing diets, conversations focused on weight loss, and the discussion of weight and health may be good, ultimately the impact clearly is not. In my weight-inclusive practice I focus on helping people work towards their goals around health and wellness without a focus on the scale. Taking the focus off of weight is ultimately far more health promoting and life-enriching.

To learn more about shifting our perspective to focusing on behaviors over weight this review and this one are excellent. If you aren’t sure about your own implicit biases – those biases we have that are outside of our consciousness and control – and would like to better recognize those biases and raise your awareness in that area, check out Harvard’s Implicit Bias Test. If you want to learn more about these concepts in general, please visit The Association for Size Diversity and Health.

If you are a doctor, medical professional or business and are interested in you and your staff raising awareness about weight stigma and bias and how we can help without causing further harm, please contact me. I am available to virtually present to you and your office.