Part 2 of my two-part series on weight stigma was in the Tallahassee Democrat in May and I realized I didn’t post it here. In this article I talk about anti-fat bias and weight stigma in medical research and media and the research and reporting around weight and COVID-19. You can see the article in the Democrat here or read it below.
A Different Perspective on COVID and Weight
In my last article I wrote about weight bias and stigma and its wide reaching impact. Anti-fat bias and stigma also show up in research and in the media and headlines too as we've seen with the many reports on the association of weight and health as it relates to COVID.
From very early on in the pandemic the rhetoric being reported around 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. It is our societal go-to scapegoat. 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 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 in recommendations around weight and health are flawed, unhelpful and ultimately do more harm than good.
More to the Story Than What We Hear
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 regard 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. We still lack full scientific understanding of the link between weight and COVID outcomes and it is important to ensure associations and results account for race/ethnicity, socioeconomic status, quality of care, or preexisting individual health risks that may worsen outcomes of the virus “ all important confounding variables that could explain some of the outcomes. Some have controlled for some of these factors and others have not. 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 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.
A Complete Look at the Data
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 imply causation is a basic tenet of research 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.
A great example of correlation, not causation is with smoking, yellow teeth, and lung cancer. Smoking cigarettes causes yellow teeth; it also causes lung cancer. Although yellow teeth are strongly correlated with lung cancer, it doesn't mean they cause lung cancer.
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.
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 local dietitian about COVID and weight, it was suggested that at this point in time doctors need to be not only talking with and counseling 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 strongly 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. Weight loss is typically praised, no matter the method or reason behind it.
Some consideration and awareness is also warranted around 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, what the research bares out is that is not helpful and ultimately reinforces the many negative impacts 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. The persistent touting in the media of risks related to being at a higher weight are not helpful, although that may be the intention, but instead serve to further stigmatize people in larger bodies and worsen health, not improve it.
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 of their bodies. It is not only NOT helpful but is deeply harmful. Whether we are in the midst of a global pandemic or not, 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.