Call for a New Agenda in Obesity Research
by Sally E. Smith

A year ago last April, the New York Times heralded the beginning of a "new anti-diet movement." While the size acceptance movement has been saying that diets don't work for a quarter of a century, it indeed seems as though the scientific community is beginning to see the light. Seemingly, at least once a week you hear of new evidence about the inefficacy of weight loss diets.

Now that the proverbial cat is out of the bag, researchers are scrambling to find ways to continue to receive funding from both the National Institutes of Health (NIH) and the commercial weight loss industry, the two main sources of funding for obesity research. For the most part, researchers are digging in their heels, continuing to try and find ways to make fat people thin. The latest trend is to focus on lifelong drug therapy or weight loss surgery as the "cure" for fatness.
It seems clear that the time is ripe for the size acceptance movement to influence how federal research money is allocated, and to help prioritize the obesity research agenda. As consumer advocates for the population affected by public health policy about obesity, the National Association to Advance Fat Acceptance (NAAFA) has begun a dialogue with the NIH. NAAFA hopes to share the responsibility for developing strategies for dealing with fatness, assist in reviewing proposals and outcomes, help to set research priorities, and review conference agendas to ensure that a balance of viewpoints are represented.

NAAFA's perspective is that, historically, obesity researchers have asked, "How do we make fat people thin?", assuming that thinness is more desirable than fatness, that fatness increases health risks, that permanent weight loss is possible, and that weight loss mitigates morbidity factors and increases longevity. These assumptions run contrary to our experience as fat people, which is that permanent weight loss is impossible to achieve, that dieting makes us fatter, that many of us are healthy, and that valuing thinness over fatness is a cultural bias. Because of our experience, and because of recent research which has validated our experience that permanent weight loss is elusive and that weight cycling has a negative impact on health, we believe researchers should be working to find the answers to the question, "How do we make fat people healthy?" From our viewpoint as consumer advocates, it seems clear that tremendous financial resources have been spent in a vain attempt to change the natural bell curve of human weight distribution.

Therefore, we would like to see obesity research funded which would address issues of how to make fat people healthy and increase their well-being, independent of weight loss. Following are some of the areas we suggest could be investigated:

There is evidence that exercise increases health and well-being, but most existing research studies exercise in relation to weight loss. We would like to see the direct impact that exercise has on morbidity factors, independent of weight loss. It would also be helpful to discover what forms of exercise are most beneficial and least stressful to the fat body.

A related issue is the barriers that fat people face when they undertake an exercise program. According to an article in the New York Times reporting on a recent Centers for Disease Control study, the Clinton administration is considering a national survey asking people why they do or do not exercise, and what discourages them from being active. Many fat people enjoy movement and would like to be more active, but cannot due to the lack of adequate equipment and apparel, the difficulty in finding an environment free from harassment and prejudice, and past negative experiences they have had with exercise.

As children, many fat people had negative experiences with physical education classes, in part because the activities proscribed were not appropriate to the abilities of the fat child. It seems important to study the factors that influence children to form habits of regular exercise, and to discover adaptable physical education programs for children that would enable and encourage them to be active throughout their lives.

There is evidence that weight cycling has negative health consequences. Because most fat people have spent years yo-yo dieting, it seems possible that many of the morbidity factors traditionally associated with fatness are actually related to weight cycling. It would be valuable to investigate the relationship between weight cycling and morbidity factors.

During the refeeding cycle following a weight loss attempt, many people experience a weight gain in excess of the number of pounds originally lost. For this reason, it seems important to study the contribution of weight cycling to increasing weight over time.

It has been our experience that weight cycling and rapid weight gain have a profound psychological impact, one which could bear further study.

From our perspective, obesity research rarely acknowledges the larger social context of the experience of being fat in our society. It seems logical that social stigma plays an important role in an individual's psychological and physical health. We believe that it is vital to study the direct health effects of social stigma, and how reducing social stigma can positively affect a fat person's health.

Because populations of non-dieters have not been studied (and have perhaps not been found), more research seems necessary to discover if fatness actually causes morbidity. If, in fact, fatness does cause morbidity, do these conditions mean the same thing in the fat population as they do in the average size population, and are there related mortality risks?

It would also seem valuable to discover if there are health benefits to fatness, and whether fatness cures or ameliorates any diseases. For example, how does having extra estrogen affect fat women after menopause? The general assumption is that fatness is unhealthy, yet why is it that many fat people are healthy (e.g., normal cholesterol and glucose levels, absence of hypertension, etc.)?

It seems evident that the fat population is heterogenous, yet most obesity research does not acknowledge this. For example, it seems ironic that some research indicates that the negative health consequences of fatness are most severe in men, yet treatment is almost always directed toward women. Likewise, tables listing optimal weights or BMIs seem to be based on the white population. When studying the health consequences of fatness and determining strategies to improve the health of fat people (independent of weight loss), differences based on gender, ethnicity, and gender within an ethnic group need to be taken into consideration.

Likewise, it appears that all people who are 20% over "ideal" weight are often treated as if they are categorically the same. It seems important to consider different levels of fatness when addressing health issues.

It is our position that all weight loss surgery should be discontinued, due to lack of knowledge about the mechanisms involved, non-standardized techniques, absence of lifelong patient care, the myriad side effects, the unknown effect on morbidity and mortality, and the absence of satisfactory studies about the long-term effects of the surgery.

From our perspective, the health consequences of fatness are not easily separated from the way in which health care is delivered to the fat population and the way fatness is viewed by the patient, the provider, and our society. Fat people are often denied access to the health care delivery system because we are discriminated against by the insurance industry. In addition, health care providers sometimes refuse to treat fat patients until they lose weight, assume all presenting symptoms are weight-related, lack adequate diagnostic equipment (from blood pressure cuffs to MRIs), prescribe inappropriate treatment, and harass fat patients about their weight. These factors, as well as the internalized shame and guilt about being fat, often result in fat people avoiding preventative care and delaying in seeking care for health problems. In order to develop strategies for improving the health of fat people, it seems crucial that the issue of effective medical care be addressed.

It appears that most obesity research is done in a university setting, and that realistic applications for research are not explored. For example, it seems that lifestyle changes are an effective means of mitigating morbidity factors and increasing longevity, and there seems to be evidence that a small amount of weight loss can improve an individual's health status. Yet many fat people do not try and modify their lifestyle because they are given the message that it won't be enough, that they must lose a large amount of weight to make a difference in their health, despite there being no evidence that a large amount of weight loss can be maintained over a five-year period.

There seem to be conflicting findings about the relationship between fatness and longevity. Given the complex nature of fatness, the heterogeneity of the fat population, and issues of receiving adequate and appropriate medical care, the findings seem even less conclusive. What would be more helpful would be to discover the roles that dieting and weight cycling play in mortality rates. We would very much like to see the CDC find a way to track deaths due to dieting and weight cycling.

One of our ongoing concerns are the potential conflicts of interest and biases that may compromise the objectivity of obesity research. While I understand the reality of the general lack of federal funds available for research, it is disturbing that the commercial weight loss and pharmaceutical industries fund obesity research, underwrite obesity research conferences, and retain obesity researchers as consultants. We feel it is very important for funding sources to be disclosed when research findings are published.

Given the information that is coming out about the long-term ineffectiveness of dieting, the time seems ripe for a paradigm shift in the obesity research community toward finding ways in which to improve the health and well-being of fat people independent of weight loss. It seems clear that more federal money will have to be spent in order to ask these kinds of questions, as there won't be the motivation for potential economic gain from the private sector. Another observation is that established researchers have established biases, particularly if they've spent their lives working toward finding ways to make fat people thin, and if they're well-connected with the private sector. These competing needs could compromise a researcher's ability to separate weight loss from health issues. To begin asking these different kinds of questions, it seems clear that new, innovative thinking will have to be incorporated.

It also seems as though much of the research that receives funding is relatively short-term, yet short-term research won't really answer questions about the long-term effects of weight cycling, morbidity factors, and mortality. Knowing that funding dollars are limited, it may be more practical to fund fewer studies, but studies that are of a longer duration. ß