When Perfect Is the Enemy
As humans we often rely on external signals to assess overall well-being. The common perception that a thin person is more healthy than an overweight person remains a modern opinion that is difficult to change. The reality of the twenty-first century is that more people are overweight or obese than ever before in human history. Studies have shown that while weight can have some impact on propensity for certain diseases and earlier death, there are other indicators that those who are overweight, (not morbidly obese) physically fit, and active, enjoy similar health benefits to normal* weight adults. With no significant breakthroughs on the horizon, a majority of people who are currently overweight, will remain so throughout their lives.
You’ve finally gone in for a yearly check-up, (after five years without one) and while your blood pressure is a little high, and you’ve not been sleeping well — probably because you’re working loads of overtime hours at a very stressful and demanding job — your overall health metrics are within acceptable limits and you feel pretty good on a day-to-day basis. With this information at hand, rather than talking about how stress might impact health, your doctor insists that you must lose 35–50 pounds (15–23 kilos) or increase your risk of developing diabetes, heart disease, stroke, or even cancer.
There are no follow-up questions about what you eat, or how often; whether you get regular exercise, or, if there have been any other physical or mental changes in recent months which might have an impact on your current lifestyle, such as chronic infections, GI-tract issues, a divorce or breakup, death of a loved one, increased pressure at work or a dramatic change in financial circumstances.
Leaving your appointment you feel quite depressed, and concerned that your apparently horrible eating habits have destined you to develop life-altering conditions which will impact your longevity by decades. Going in you felt reasonably healthy, now, you feel at death’s door, doomed by the excess fat around your middle that you had always thought of as a family trait, and an unavoidable consequence of aging.
Losing weight continues to be the single most common “cure” for improving overall health if a patient is overweight.
BBC News recently ran a story that claimed obesity is reaching crisis levels in Britain, and the NHS are investigating methods of encouraging people to lose weight to improve their health, and to help prevent diseases like diabetes and heart attacks, which take a massive financial toll on the economies of many developed nations. Taken at face value, this seems a positive step in preventative health measures, but, is losing weight the single best answer to improving health outcomes for those caught in the “obesity epidemic?” The latest research seems to indicate the answer is a resounding no, but prescribing weight loss remains the standard of care offered to people whose body mass index (BMI) has tipped above the “normal” range, regardless of overall health, eating habits, exercise participation, or previous efforts at reducing weight.
Most medical and health professionals (and everyone else, tbh) view weight gain as a monumental failure of control. Generally, the thinking is that people get fat if they are lazy, or lack the willpower to choose only “healthy” foods, maintain a calorie-controlled diet and participate in regular, intense cardio activity. The fact that this same lack of willpower is evident for most thin people as well, seems to be lost. Losing weight continues to be the single most common “cure” for improving overall health if a patient is overweight.
Human beings (and even some animals) are getting heavier. The percentages of those who are overweight, obese, and morbidly obese are rising, in some countries, at an alarming rate. In 1961 only 13% of Americans were considered obese. Then, between 2009 and 2012, that number rose, to nearly 36% of all adults between the ages of 20 and 74. That’s more than one in three, and the numbers are forecast to continue rising over the next decades as childhood obesity is also rising, at correspondingly high rates.
Being overweight is blamed for a myriad of physical ailments and diseases, and losing weight is often the go-to treatment on offer from doctors, nutritional consultants (aka the diet industry) and fitness professionals. Why? Because this very obvious physical attribute is something medical professionals and health-related experts can easily point to as a clear manifestation of poor lifestyle choices.
Doctors regularly scold their patients for gaining weight, or not losing enough of it, and will point to being overweight for all manner of non-related illnesses or symptoms. Overweight patients are routinely fat-shamed, ignored or misdiagnosed because their physicians can’t see beyond fatness as the cause of their health concerns.
It is an unfortunate truth, but there is a tendency for those in the medical, nutrition and fitness fields to demand commitment to a pre-condition of losing significant weight first and foremost, while withholding, or actively discouraging those who are overweight from participating in exactly the treatments, education, and activities which might genuinely improve their health. There is ample evidence, both documented and anecdotal, that confirms the tendency for health professionals to ignore all other diagnoses if a patient/client exhibits the very obvious physical symptom of being overweight.
After your check-up, you decide to research weight loss plans and methods and mentally commit to losing at least 25 pounds (11 kilos). Less than your doctor suggested, but a seemingly achievable goal. A quick check of the Internet overwhelms you with information on how to lose weight, burn fat and get super fit — quick. You’re so excited about these great opportunities, you immediately decide that you will get into the best shape you’ve ever been in your life and up your weight loss goal to 60 pounds (27 kilos).
There is no shortage of options and they all promise to make the pounds disappear, often without hunger pangs, loss of energy, or serious medical side effects. The one that catches your eye though is AspireAssist, a non-surgical bariatric device that “allows you to remove about 30% of the food from the stomach before the calories are absorbed into the body, causing weight loss.” It seems a bit weird that bulimia is horrible when it’s a thin person’s eating disorder, but it’s perfectly dandy if a doctor attaches a device that allows you to vomit through a hole in your stomach in a discreet, yet time-consuming way.
Unfortunately, after a little more searching and becoming completely grossed out, it seems that most diets don’t work long term, bariatric surgery is extremely expensive, and only for the morbidly obese, and the latest research suggests that keeping weight off long term is so rare it’s only hypothetically possible. You feel completely confused about what to do next.
“Willpower and perseverance have almost nothing to do with maintaining a “normal” weight.”
Almost everyone can tell you that to lose weight, one must “eat less, exercise more.” It’s a simple prescription which guarantees results, right? Well, not right actually. Most research being done today finds that there are many factors which have impacted on the changing shape of our waistlines since the 1960s. While it is true that our lives have become more sedentary, and our foods of choice more calorie dense, these factors alone could not have caused the exponential rise in weight gain which has been observed around the world.
The stark reality is that more people are becoming overweight or obese, and the majority of these people will never lose that weight and keep it off permanently, or even long term. In fact, those who lose significant amounts of weight are almost guaranteed to regain all of it, plus more.
Overweight people are constantly blamed for their circumstances, even though there is increasing evidence that there are many factors, both internal and external which contribute to weight gain in individuals. Willpower and perseverance have almost nothing to do with maintaining a “normal” weight. Some people can remain thin with relatively little effort, and no particular intention to eat nutritiously or exercise dutifully, while others will watch every mouthful and pack on additional weight regardless of their intention and effort to avoid doing so.
So, a majority of people who are currently overweight, will remain so throughout their lives. Others will cycle through higher and lower weights, each time regaining more weight than was lost, which actually places them at an even higher risk for developing cardiovascular disease, diabetes and stroke. Repeated weight loss is not a useful or economically viable way of improving health outcomes.
Studies have shown that while weight can have some impact on propensity for certain diseases and earlier death, there are other indicators that those who are overweight, (not morbidly obese) physically fit, and active, enjoy similar health benefits to “normal” weight adults. In fact, people whose BMIs are in the overweight range (BMI is itself a notoriously bad method for determining “healthy” weight, especially for women btw.) actually have lower mortality rates than those with “normal-range” BMIs. This is sometimes called the Obesity Paradox and it’s still quite controversial because, of course no one believes that overweight people might be better off maintaining a consistent (albeit higher) weight over a lifetime.
The reality is that overweight and obese adults who participate in regular, moderate exercise and lower their body weight by as little as 5% can bring down both blood pressure and blood sugar and improve their health overall. Being a little bit fat, but also physically fit means you will probably not die any sooner than a thinner person — so tell us again why thin is considered the more healthy body type?
Now that you’ve been completely put off dieting or surgical interventions, you pledge instead to eat more nutritious foods and enjoy fewer indulgences, foregoing your occasional afternoon candy bar and drinking one less glass of wine with dinner. It feels like a positive step, though you worry that your doctor will not feel the same. You will probably wait another five years before your next check-up.
You do decide to make an effort to get more physically fit. You haven’t been to a gym since your college days when high-impact aerobics were still the craze. Being older has brought on some aches and pains, and sitting at a desk all day makes your back hurt. Sometimes your hips and knees ache after taking the stairs. The thought of walking into a gym fills you with dread. You think everyone there will be young, thin, and super fit with six-pack abs and buns of steel like Jamie Leigh Curtis in Perfect.
A friend invites you to join her in a High Intensity Interval Training (HIIT) class she loves. Once there, you dream of quitting after ten minutes of listening to a creepily intense twenty-something woman scream at you to “Go harder!” “No Excuses!” and “Never Give Up!” The instructor never introduces herself, asks if this is anyone’s first class, or makes any effort to show lower intensity options to the participants, even though you are very obviously not the only one struggling to keep up. You really, really want to give up, mostly because you can’t actually accomplish (much less understand) most of the moves she is wildly demonstrating. You sense that everyone else in the class is staring at you, making you feel that someone of your age and body type is not welcome to invade this temple to perfection.
As you stumble out at the end of the HIIT class, you look across the hallway to see a cycle class just finishing up. It’s being taught by a pleasant-faced woman who’s probably in her forties. She smiles and waves for you to come in. She introduces herself and asks if you’ve just joined the gym. You say you haven’t even joined yet and aren’t likely to, based on the HIIT class that just about killed you (and all your good intentions to improve your fitness). With a tiny smile, she suggests you might try a cycle class, as they are good for beginners, offer a low-impact, variable intensity workout, and everyone is encouraged to work at their own pace. She explains the benefits of cycling, particularly for those with joint issues. You promise to return in a few days to take her class.
With a great deal of apprehension, you finally go back to the gym for a cycle class. There is a different instructor, but she welcomes you in and asks if you’ve ridden a stationary bike before. When you say no, she helps you set up the bike and explains a few simple instructions for riding comfortably. As the class starts, the instructor is encouraging and cheerful, congratulating everyone for coming in. She reminds the participants that they should work at their own pace, but coaches everyone when to push a little bit harder, and when to take time to recover. Looking at the instructor, you would never guess she could be so fit. She’s a bit overweight, but she works hard through the entire class, and a small puddle of sweat is glistening on the floor below her bike. You want to be like her and you want to be as fit as she is. This seems totally possible in your mind. The future looks brighter already.
“It is extremely difficult for most people to achieve such high levels of fitness, strength, and yes, thinness.”
Exercise can improve health for everyone, not just those wanting to get thinner. What’s most important is to find a routine that works with each person’s abilities and (realistic) goals. Most fitness facilities offer the promise of every member transforming into a perfect, super thin, super fit, (or muscular) vision of themselves. This is an empty promise as it is extremely difficult for most people to achieve such high levels of fitness, strength, and yes, thinness. Exercise should be highly recommended for everyone, but with a realistic set of goals based on age, interests, current fitness levels, physical impediments and time constraints.
Physical fitness doesn’t have to happen in a gym, and in many situations gym environments can actually deter non-size conforming members. Effective exercise doesn’t have to be cardio-intensive or difficult. Current recommendations are for 150 minutes of moderate exercise per week, or, about 30 minutes per day. Walking the dog, gardening, heck, even going up and down stairs counts. There is no one particular way to exercise, and the best results happen when the exercise is safe, suitable and manageable for the person doing it. If exercise helps to improve lives, then let’s make it possible to improve life for everyone.
“The evil view of obesity has come from four places: the insurance industry, the medical moralizers, the drug industry and the docile, unquestioned nutritionists who are too often dupes of faddists and hucksters.” — George Mann, Physician
Very, very few people are intentionally obese, and I have never met a single overweight person (myself included) who wasn’t self-aware, or willing to acknowledge that maybe they just aren’t able to maintain a thin body, no matter how hard (or how many times) they have tried. This is a horrible burden which we place on people who, in most cases have been so manipulated, shamed, or humiliated about their appearance that they often believe they don’t deserve any compassion from those who should support their efforts towards better health.
It is possible to change perceptions of what healthy and athletic can look like, and some influential people and channels are stepping up to help us realign our awareness of the variety of human sizes and shapes in our modern-day world. (Others, not so much.) As more children grow up to become overweight or obese adults, it must become unacceptable to express judgmental opinions about appearances, or pretend that somehow thin people are better people only because they are thin.
Some fitness organizations are beginning to address the reality of fitness at every size, and are actively promoting training for fitness professionals that are sensitive to the needs of non-athletes, with particular focus on obese, children, or senior-aged clients.
More and more, we see intentional efforts to call out false, shaming and misleading advertising. London’s mayor, Sadiq Khan, has banned ads which might cause body confidence issues, such as the infamous “Beach Body Ready” placards seen on public transport last year, saying:
“Nobody should feel pressurised, while they travel on the Tube or bus, into unrealistic expectations surrounding their bodies and I want to send a clear message to the advertising industry about this.”
Pope Francis has also recently spoken out on the marginalization of those who can’t fulfill the demands of “superficial perfection” by calling for acceptance and respect for difference.
“The world does not become better because only apparently ‘perfect’ — not to mention ‘made-over’ — people live there, [but] when solidarity and mutual acceptance and respect increase.”
Can we adapt healthcare systems, nutritional best practices and fitness programs to accommodate and encourage populations seeking access to appropriate medical treatment, nutritional support, and fitness plans regardless of size? Right now, these institutions are fraught with obstruction, misguided assumptions and misaligned perceptions.
The top of mind goal should be to inoculate future generations to be less susceptible to becoming obese, through competent and appropriate healthcare, access to adequate, nourishing food and regular physical activity, but the battle lines should be drawn to ensure that those caught by historical trends in healthcare, nutrition, and fitness are not further disadvantaged by inappropriate treatment from those in these care professions, which currently manifest additional burdens to their ongoing good health.
Doctors should listen to their patients and work with them to find forms of treatment not based solely on weight or visual signals of health. Nutritionists should educate their clients on how to better feed their bodies, and gyms, trainers, and other fitness professionals should welcome every participant — without judgement or a pre-requisite of committing to get thinner. Let’s not let an imagined perfect be the enemy of the realistic good.
*In this article, I use “normal” in quotation marks because there is very little agreement about what a normal weight should be. I have also used caution with words like “healthy,” which should never be used to describe foods, or choices, and “fitness” which is generally ascribed such a narrow, visual definition as to be meaningless for the general public.