The article opens by describing him as “an immense man, well over 300 pounds, but in the gravity of his sorrow and shame he seemed larger still.” It then says that he “hunched forward in the sturdy wooden armchair that barely contained him.”

The sentence makes fatness the visible form of shame. He is not allowed to be a grieving person whose body happens to be large; his grief is converted into additional size, additional excess, additional evidence that he is too much for the chair and perhaps too much for the world around him. His grief is not represented through his face, voice, posture, or words. Shame is represented as the intensification of his fatness. The sentence effectively says: his body was already too much, and his moral suffering made it even more excessive.

Any parent coming into this story feels fear and horror and empathy and terror and HOW COULD THIS HAPPEN and I HOPE THIS NEVER HAPPENS TO ME. But before we are allowed to sit with any of that, the reader is instructed to look at how fat this man is and imagine the furniture struggling to hold him.

And I think we all know that he didn’t leave his child in the car because he was fat.

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We would recognize how fucking inappropriate and cruel it would be if the sentence said that a Black defendant, in the gravity of his sorrow and shame, seemed Blacker still. The histories of fatness and Blackness are not interchangeable, but they are connected. The sentence treats an identity marker as something that can intensify when a person is morally condemned.

Someone will say that the article was published 17 years ago, so this is old shit. We have body positivity now! We’ve grown as a culture.

But have we??

The language is old, but the pattern is everywhere. We find it in novels, television, hospitals, airplanes, waiting rooms, and the private calculations fat people end up having to make even before just fucking sitting down in public.

What persists is a vocabulary: fill, spill, strain, creak, burst, collapse. Literary scholar David Loría Araujo calls this a “ritualization” of fatness and describes the “semantic lots” of the fat body as the recurring tropes, adjectives, and value judgments that shape how fat characters are read (Loría Araujo, 2017). He also writes about the hyperbole and grotesque deformation that make fat characters less than human (Loría Araujo, 2017).

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I was re-reading Eragon to my kids and there it was, staring at me, fatly. A fat trader “filled a chair with his enormous girth,” and every movement caused the chair to “protest loudly”; he tried to pull his “expanding borders” back inside it. His body is not one detail in a larger portrait. It is the device the author uses to make him ridiculous, childish, disgusting, and morally suspect.

In 2026, the cultural shorthand of fatness has remained largely unchanged, and I probably don’t need to tell you what fatness serves as a “stand-in” for because you’ve already become acclimatized through media consumption.

Fatness is often made to carry greed, laziness, disgust, and lack of self-control, so the body can do the work of characterization before the character has done anything at all (Brown, 2013). As though we needed more evidence that JK Rowling is trash , the Harry Potter books are a cultural touchstone that most people don’t even realize are viciously fatphobic.

Dudley’s body does not merely get called large: it “drooped over each side of his chair,” his trousers are described as “slipping down his fat bottom,” and, when he falls out of the chair, the crash “shook the whole kitchen.” Slughorn is even more literal. Where an armchair had been, Harry sees an “enormously fat” man; elsewhere, Slughorn’s girth takes up most of a train compartment (????) and his stomach is said to precede him into rooms. And the more you think about either one of these descriptions, the more ludicrous and unfathomable they become. Train cars may be small, but jesus. What?

It gets worse when you realize how manufactured all this not-fitting actually is. Somebody designed the chair, the airplane buckle (Rinaldi et al., 2020), the hospital gown, and the examination table . The stigma is built into these spaces, not just into individual interactions (Nourse et al., 2025) . When a fat person cannot use them comfortably or safely, the design decision disappears and the body gets blamed instead. Fat people enter public spaces already calculating whether we will fit, break something, inconvenience somebody, or become visible in the wrong way.

What people write is not just a reflection of our society, but an instruction manual for its continuance. A review of media research found that when people are repeatedly shown the same body ideal, they can start to treat it as a standard and measure themselves against it, affecting how they feel about their own bodies and weight (López-Guimerà et al., 2010). We carry those images and that vocabulary into the room with us, learning to treat things designed to exclude us as possible evidence that our bodies are wrong (Kyrölä, 2016).

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I have never paused to listen for the sound of a chair when someone sits down, but as a person with a generous posterior, I have absolutely been convinced that other people are doing it.

What a weird cultural expectation.

Writers give chairs feelings, pain, and a voice: they protest, complain, groan, strain, and suffer under the body sitting in them. Meanwhile, the fat person is no longer treated as a person with thoughts or feelings. We become the burden on the chair, the threat to the furniture, the event everyone is just primed, listening for, as our asses approach the seat. The chair gets to be vulnerable; the fat person is the real problem. We humanize the chair in order to dehumanize the person. A fat person sitting down becomes a spectacle that requires witnesses, commentary, and a punchline .

Research on television has documented fat people being shown getting stuck, being lifted, or being unable to fit into equipment, using their bodies to communicate that they do not belong in the space (Raphael, 2008). Another study looked at the images running alongside online news coverage on five major news sites and found that 72 percent of the photographs of people described as overweight or obese portrayed them in stigmatizing ways, with more than half showing only an abdomen or a lower body, a framing the same outlets never used on anyone thin (Heuer, McClure, & Puhl, 2011).

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I do not need to prove that every author who writes a chair this way consciously hates fat people. I do not even need to pretend this was written by some random thin outsider. The author, Gene Weingarten, is a self-professed fat, writing a whole substack called “I’m Fat”. That complicates the story, but it does not cancel the harm; the internet is FULL of self-hating fats. Fat people are just as capable as skinny people at absorbing and reproducing fatphobic language, in some cases, moreso. The question is what the language does: it turns a design problem into a character description and a person’s body into a moral explanation.

The man in the Washington Post story had already lost his child and entered the public machinery of grief, criminal judgment, and shame, but the article still recruited his body as another piece of evidence against him. The world keeps making spaces that do not fit us, then asks us to carry the embarrassment and shame for not fitting. Fat people are not constantly invading and breaking public space; public space is constantly asking us to prove that we belong in it, and authors keep writing down the sound of us failing the test.

Author’s Note/PostScript:

References

Brown, A. (2013). The elephant in the room: Fatphobia & oppression in the time of obesity [Master’s thesis].

Heuer, C. A., McClure, K. J., & Puhl, R. M. (2011). Obesity stigma in online news: A visual content analysis. Journal of Health Communication, 16(9), 976–987. https://doi.org/10.1080/10810730.2011.561915

Kyrölä, K. (2016). The weight of images: Affect, body image and fat in the media. Routledge. https://doi.org/10.4324/9781315551463

López-Guimerà, G., Levine, M. P., Sánchez-Carracedo, D., & Fauquet, J. (2010). Influence of mass media on body image and eating disordered attitudes and behaviors in females: A review of effects and processes. Media Psychology, 13(4), 387–416. https://doi.org/10.1080/15213269.2010.525737

Loría Araujo, D. (2017). Escrituras del cuerpo gordo en Salvador Elizondo y Guadalupe Dueñas. Acta Académica.

Nourse, G., Farrugia, A., Seear, K., Lenton, E., Cama, E., & Treloar, C. (2025). Stigmatising space-times: Addressing healthcare stigma beyond interpersonal interactions. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine. https://doi.org/10.1177/13634593251323000

Raphael, D. (2008). The social construction of obesity in New Zealand prime time television media [Master’s thesis]. Massey University.

Rinaldi, J., Rice, C., & Lind, E. (2020). Failure to launch: One-person-one-fare airline policy and the drawbacks to the disabled-by-obesity legal argument. Fat Studies: An Interdisciplinary Journal of Body Weight and Society. https://doi.org/10.1080/21604851.2020.1745359

Weingarten, G. (2009, March 8). Fatal distraction. The Washington Post. https://www.washingtonpost.com/archive/lifestyle/2009/03/08/fatal-distraction/88d4794a-1a96-4ad8-b372-12bc63eb35a7/

Weingarten, G. (2025, April 29). I’m fat. The Gene Pool.

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a year ago · 41 likes · 78 comments · Gene Weingarten

Of course, there are people saying that even suggesting this in practice is crazy. No one would actually eat contaminated lettuce on purpose just to lose weight. Right?

When Adam and I came home from Congo, he came home sixty pounds lighter, thanks to having suffered through malaria five times in under a year. And I remember fielding MULTIPLE “jokes” from friends, asking me if we’d brought home malaria for them too, because they needed to lose some weight and didn’t Adam look great.

I’m not sure if/why it’s necessary to say, but malaria is not a trendy diet. It is a serious parasitic disease. The World Health Organization estimates that malaria killed 610,000 people worldwide in 2024 alone (World Health Organization, 2025). Depending on the species and the speed of treatment, it can lead to severe anemia, kidney failure, respiratory failure, seizures, coma, and, eventually, death. Some forms can worsen rapidly, even within a day (Centers for Disease Control and Prevention, 2026).

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Cyclospora is not as serious as malaria, but it shouldn’t be considered a diet or weight-loss shortcut either. You’re not in for a good time eating diarrhea lettuce on purpose. But it isn’t the first time we’ve joked about the lengths we’re willing to go to to lose weight, and it certainly won’t be the last.

These examples are at the edges of normal, or at least I hope they are. I’m sure elder millennials like me remember people in the 80s joking about getting a tapeworm on purpose to lose weight. The joke only works because the underlying idea is familiar.

Namely, that any degree of suffering, danger, discomfort, extremeness, and irresponsibility is worth it if the outcome is thinness.

Nothing tastes as good as skinny feels, after all.

I don’t have to tell you that the irony is striking, considering that people conflate thinness with health, and if you’re doing every insane unhealthy thing in order to GET thin, how are you on the path to health and wellness?

These examples - malaria, diarrhea lettuce, tapeworms - they’re all crazy fringe things, right? Normal people don’t do super unhealthy insane things to lose weight, right?

There are so many things marketed as reasonable ways to lose weight that people don’t recognize how dangerous they can be.

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Mainstream interventions like Fen-phen were treated as ordinary medical solutions. In 1996, more than 18 million prescriptions for fenfluramine and phentermine were filled in the United States. The combination was later associated with valvular heart disease, pulmonary hypertension, and cardiac surgery, while fenfluramine was linked to severe, sometimes persistent neuropsychiatric effects, including depression, anhedonia, anxiety, cognitive problems, and impaired impulse control. Some people also developed severe, sometimes lasting problems with their mood and their ability to feel pleasure. More than four years after people stopped taking the drugs, brain scans still showed changes in the way their brains handled serotonin. (Connolly et al., 1997; McCann et al., 1998, 2007)

Fen-phen isn’t even the only drug to have a “whoopsie” moment with safety after being prescribed broadly by doctors. A systematic review found that most centrally acting anti-obesity drugs withdrawn since 1950 had been removed because of adverse reactions, including psychiatric disturbances, cardiotoxicity, dependence, or death (Onakpoya et al., 2016). And that’s just the prescription-drug version of the problem.

People have also flocked to Metabolife, Hydroxycut, laxatives, and whatever new supplement promises to make weight loss easier. Metabolife’s ephedra-containing products were linked to heart attacks, strokes, seizures, and deaths (Lobb, 2009). Hydroxycut was recalled after reports of severe liver injury, including cases that required transplants and one that ended in death (Fong et al., 2010). Laxatives have been used for weight loss for centuries, including by fashion models under pressure to stay thin. The weight loss is not lasting: laxatives make the number on the scale fall by causing the body to lose water, and the weight returns when the body rehydrates. Long-term misuse, however, can damage the bowel and disrupt the electrolytes that help keep the heart working properly (Bogár et al., 2022; Gibson et al., 2021; Haslam, 2016; Nitsch et al., 2021).

I won’t rehash the Ozempic argument again , but when I say that being skeptical about the safety of long-term use in yet another weight loss drug doesn’t feel unfair, and certainly DOES fall in line with the shit (metaphorical AND literal in this case) that we expect fatties to tolerate in the name of weight loss.

Hey, at least these don’t involve the literal rerouting of your internal organs!

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Lots of people on the internet seem to think that bariatric surgery is “the easy route” when it comes to weight loss. But it changes the body. Bariatric procedures can produce malabsorption, dumping syndrome, kidney stones, bowel obstruction, ulcers, reflux, bacterial overgrowth, vitamin deficiencies, loss of lean mass, and bone loss. They are not all one-time technical complications. Some are part of the physiology patients may have to manage for the rest of their lives (Moizé et al., 2024).

The consequences can appear long after the actual operation. A recent review of case reports found micronutrient deficiencies more than two years after surgery, including vitamin A, copper, and vitamin D deficiency. Some case reports described permanent disability or death afterward. Case reports cannot tell us how common these outcomes are, but they make one thing difficult to deny: “successful” weight loss might carry really serious costs that we tend to gloss over (Haughton et al., 2025).

As someone who had bariatric surgery in 2010, I still can’t eat certain foods, and I still vomit far more than most normal people. For the two years after surgery, I vomited so often that it caused a lot of other problems.

BUT LOOK, I WAS GETTING SKINNIER!!

Doesn’t that make it worth it?

If I made a list of all of the unpleasant side effects and shitty consequences (POO PUNS, haha) of these various weight-loss interventions, I would be here through next week. I can’t help but think about the “weight loss oil” Olestra from my childhood that was supposed to not be absorbed by the system and ended up just giving everyone diarrhea.

So when everyone is telling me how amazing Ozempic and its friends are and they give people nausea, vomiting, diarrhea, and constipation, it at least feels on brand with what we’ve been conditioned as fats to accept in the pursuit of weight loss (Ismaiel et al., 2025).

Why are fat people expected to accept all of this?

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Self-hatred is what weight stigma can look like from the inside. Once people absorb the idea that their bodies are failures, they can start to believe they deserve the pain, nausea, and complications that come with trying to change them. The research usually calls this internalized weight stigma, but the experience is closer to self-blame: shame turns into a reason to accept punishment (Bidstrup et al., 2022; Lee et al., 2019; Tomiyama et al., 2018).

One older study of people who had lost one hundred pounds after gastric bypass reported that they would rather be deaf, blind, have heart disease, or lose a leg than regain the weight. They also said they would give up being a multimillionaire to remain at a “normal” weight. The sample is old, and the finding should not be treated as a universal statement about everyone who has surgery. It is still a disturbing record of what weight stigma can make feel acceptable (Tomiyama & Mann, 2013).

Nothing tastes as good as skinny feels.

The question is what could be so awful in society that people become so afraid of being fat.

Fatness can feel like a glaring public failure instead of just a variation in body size. It can affect how people are treated at work, in healthcare, in relationships, and in ordinary public life. Fat people can be blamed for their size, treated as irresponsible, and given worse care. Weight stigma carries social, economic, and health consequences, so the fear of becoming fat again is fear of losing status, being disbelieved, and being punished all over again (Hand et al., 2013; Tomiyama et al., 2018; Westbury et al., 2023).

That makes it easier to understand why someone might choose diarrhea lettuce instead of fatness. Why someone would fast for days and be blurry and miserable and hungry or spend 2 hours a day at a gym that costs $400 a month to workout until they feel sick and sore. That someone might believe that they deserve to be shouted at by Jillian Michaels and forced to run on a treadmill until they barf and pass out.

I’m not sure how to tackle this issue, because part of it has to come from us, the fats, realizing that we need to be more discerning about what we accept as care. We need to be less self-hating, because I can only assume that would make us feel less deserving of punishment.

Or maybe if being fat didn’t change how you were treated in society so drastically, people would be less desperate to eat poison to shed pounds.

God forbid someone realize that you can lose SO much weight if you cut off your limbs, because once they do, we’re really in trouble.

But the takeaway is realizing that just because literal poison is on the table with a label saying “drink me to lose weight,” it doesn’t mean you should ingest it.

References

Bidstrup, H., Brennan, L., Hindle, A., Kaufmann, L. M., & Garcia, X. de la Piedad. (2022). Internalised weight stigma mediates relationships between perceived weight stigma and psychosocial correlates in individuals seeking bariatric surgery: A cross-sectional study. Obesity Surgery. https://doi.org/10.1007/s11695-022-06245-z

Bogár, N., Dukay-Szabó, S., Simon, D. M., Túry, F., & Pászthy, B. (2022). Frequency of disordered eating habits among fashion models. European Eating Disorders Review. https://doi.org/10.1002/erv.2912

Centers for Disease Control and Prevention. (2026). Clinical features of malaria. https://www.cdc.gov/malaria/hcp/clinical-features/index.html

Connolly, H. M., Crary, J. L., McGoon, M. D., Hensrud, D. D., Edwards, B. S., Edwards, W. D., & Schaff, H. V. (1997). Valvular heart disease associated with fenfluramine-phentermine. New England Journal of Medicine. https://doi.org/10.1056/nejm199708283370901

Fong, T.-L., Klontz, K. C., Cañas-Coto, A., Casper, S., Durazo, F., Davern, T. J., Hayashi, P. H., Lee, W. M., & Seeff, L. B. (2010). Hepatotoxicity due to Hydroxycut: A case series. The American Journal of Gastroenterology. https://doi.org/10.1038/ajg.2010.5

Gibson, D., Benabe, J., Watters, A., Oakes, J., & Mehler, P. S. (2021). Personality characteristics and medical impact of stimulant laxative abuse in eating disorder patients: A pilot study. Journal of Eating Disorders. https://doi.org/10.1186/s40337-021-00502-9

Hand, W. B., Robinson, J. C., & Creel, E. (2013). Ethical issues surrounding weight bias and stigma in healthcare. Journal of Health Ethics. https://doi.org/10.18785/ojhe.0802.04

Haslam, D. (2016). Weight management in obesity: Past and present. International Journal of Clinical Practice. https://doi.org/10.1111/ijcp.12771

Haughton, S., Gentry, S., & Parretti, H. M. (2025). Nutritional deficiencies following bariatric surgery: A rapid systematic review of case reports of vitamin and micronutrient deficiencies presenting more than two years post-surgery. Clinical Obesity. https://doi.org/10.1111/cob.70035

Ismaiel, A., Scarlata, G. G. M., Boitos, I., Leucuta, D.-C., Popa, S.-L., Al Srouji, N., Abenavoli, L., & Dumitraşcu, D. L. (2025). Gastrointestinal adverse events associated with GLP-1 RA in non-diabetic patients with overweight or obesity: A systematic review and network meta-analysis. International Journal of Obesity. https://doi.org/10.1038/s41366-025-01859-6

Lee, M., Gonzalez, B. D., Small, B. J., & Thompson, J. K. (2019). Internalized weight bias and psychological wellbeing: An exploratory investigation of a preliminary model. PLoS ONE. https://doi.org/10.1371/journal.pone.0216324

Lobb, A. (2009). Hepatoxicity associated with weight-loss supplements: A case for better post-marketing surveillance. World Journal of Gastroenterology. https://doi.org/10.3748/wjg.15.1786

McCann, U. D., Eligulashvili, V., & Ricaurte, G. A. (1998). Adverse neuropsychiatric events associated with dexfenfluramine and fenfluramine. Progress in Neuro-Psychopharmacology and Biological Psychiatry. https://doi.org/10.1016/S0278-5846(98)00063-3

McCann, U. D., Szabó, Z., Vranešić, M., Seckin, E., Wand, G. S., Duval, A., Dannals, R. F., & Ricaurte, G. A. (2007). Quantitative positron emission tomography studies of the serotonin transporter in humans previously treated with the appetite suppressants fenfluramine or dexfenfluramine. Molecular Imaging and Biology. https://doi.org/10.1007/s11307-007-0082-7

Moizé, V., Laferrère, B., & Shapses, S. A. (2024). Nutritional challenges and treatment after bariatric surgery. Annual Review of Nutrition. https://doi.org/10.1146/annurev-nutr-061121-101547

Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine. https://doi.org/10.3949/ccjm.88a.20168

Onakpoya, I., Heneghan, C., & Aronson, J. K. (2016). Post-marketing withdrawal of anti-obesity medicinal products because of adverse drug reactions: A systematic review. BMC Medicine. https://doi.org/10.1186/s12916-016-0735-y

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity “epidemic” and harms health. BMC Medicine. https://doi.org/10.1186/s12916-018-1116-5

Tomiyama, A. J., & Mann, T. (2013). If shaming reduced obesity, there would be no fat people. The Hastings Center Report. https://doi.org/10.1002/hast.166

U.S. Food and Drug Administration. (2026). Investigation of 15-state outbreak of Cyclospora illnesses associated with iceberg lettuce. https://www.fda.gov/food/outbreaks-foodborne-illness/investigation-15-state-outbreak-cyclospora-illnesses-iceberg-lettuce-july-2026

Westbury, S., Oyebode, O., van Rens, T., & Barber, T. M. (2023). Obesity stigma: Causes, consequences, and potential solutions. Current Obesity Reports. https://doi.org/10.1007/s13679-023-00495-3

World Health Organization. (2025). Malaria. https://www.who.int/data/gho/data/themes/theme-details/GHO/malaria

The girls were probably 11 or 12, old enough at Pennsic to be unsupervised, and none of them seemed to understand how alarming it was to hear literal children talk about their bodies this way. I told them that they shouldn’t worry so much about being skinny, and that anorexia is a deadly illness, not a diet plan (Martínez-González et al., 2020). I don’t think it made much impact, considering that they apparently didn’t even know what anorexia was.

It was cringe to interrupt. I could feel myself being THAT adult nobody had invited into the conversation. But it was also impossible to sit there and listen to these girls pick apart their bodies as if it were normal and okay.

But let’s be honest. It felt normal and okay to them because, in many ways, it is the norm.

I am a mid-forties elder millennial, which means I am deluged by a constant barrage of diet announcements, workout selfies, weight-loss updates, fitness inspo, before-and-after photos, and wellness challenges from friends, acquaintances, coworkers, and people who friended me after a party in 2002 or an airplane in 2010 and then we never spoke meaningfully again.

I think about that scene from Mean Girls where everyone stands in front of the mirror and complains about random parts of their bodies. Since I started my own mental wellness journey of loving my body and identifying the toxicity of diet culture, I am now constantly feeling like Cady Heron, staring with horror as my friends and random acquaintances tear themselves apart publicly in some sort of show of compliance and/or diet culture solidarity.

I see these posts and I want to say something.

I want to ask whether they’re okay, whether they’re eating enough, whether any of this is necessary, and whether it is making their lives better or just making them more afraid of their bodies.

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And I don’t.

I scroll past because I know exactly how it will sound if I say what I’m thinking. I’ll be called mean. I’ll be told there is nothing wrong with wanting to be smaller. I’ll be accused of not supporting another woman’s choices.

Which is bonkers to me. As a candid, overintellectual woman, I’m constantly laboring under the pretense that we, as women, are here to support one another. We hold your hair in the bathroom while you barf. We tell you if some guy was hitting on other women while you were in the bathroom. In my estimation, if someone is doing something that seems kind of extreme or unhealthy to herself or to other people, the good thing is to say something, right?

But no! Somehow, weight loss shit has wiggled its way into its own category where the only way to support your lady friend is by cheering on her weight loss, even if her behavior reeks of disordered eating.

But public praise is never private; it teaches everyone else what kind of body gets rewarded. And it’s such a slippery slope, because I don’t want to imply that women are not allowed to make choices about their bodies.

What I am objecting to is the idea that the rest of us are required to pretend those choices exist outside a culture that still treats thinness as an achievement, a sign of discipline, and a measure of worth (Saguy & Gruys, 2010).

Maybe I am alone.

I have always been the woman to tell people when they have spinach in their teeth. I’m honest to a fault. Even at Pennsic, a friend asked me to comment on a top she was thinking of buying, and I told her that the pattern was not doing her breasts any favors. ( Why should that even matter? I know, I know. )

But when it comes to pushing back on constant diet and weight-loss content, I suddenly become quiet. I worry that I’ll be called a mega asshole if I say anything that goes against diet culture.

We spent all this time in feminism trying to help one another recognize when the system was manipulating us. Now, somehow, saying “I don’t think you need to make yourself miserable to be five pounds lighter” is treated as an attack on another woman’s autonomy and desire to be smaller. DON’T I WANT HER TO BE HEALTHY!??!

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It’s even worse because of what I can only describe as the girlbossification of disordered eating. We have taken the old tried-and-true business of making women smaller and put an empowerment sticker on it and a pink glittery font. We’re all heading to Pilates in our Lululemon sets to get Miley Cyrus’s arms, and of course we’re going to vlog about it. Because if you have time to restrict and work out, you are IN CONTROL OF YOUR LIFE and you eat so little at mealtime you have time to video just how little you’re eating in a day.

It’s not just a trap for susceptible dummies, either. Some of the smartest, most progressive and feminist women can spend an alarming amount of time thinking about food, calories, workouts, and the size of their bodies, and none of it is treated as a warning sign. It is treated as evidence that they are organized, committed, and in charge of their shit! YAS QUEEN??? ARE YOU A SKINNY LEGEND YET?

Restriction has been rebranded as clean eating, a calorie target, metabolic flexibility, or fasting, depending on which influencer is talking. We keep finding new and sexier ways to describe starving our bodies because “I am trying to eat as little as possible” sounds alarming, while “I am optimizing my health” sounds like a goal.

I know that people reading this post will push back because “of course” people want to be smaller and it’s their choice. And yes, it is a choice. But recognize that a choice can still be shaped by culture. It’s called a constrained choice: technically voluntary, but influenced by social pressure, incentives, and the narrow set of options we have been taught to imagine. Diet culture does not have to force women to shrink themselves. It only has to make shrinking feel like the natural, empowering, self-directed thing to do (Riley et al., 2018; Musolino et al., 2015).

It makes me think that perhaps our support of other women’s dieting efforts is shaped by the same forces. It is a performance within the system that we have all been taught to see as normal. We don’t see that support as enablement, but when we congratulate a woman for shrinking, we are not only responding to her. We are demonstrating to everyone reading that we know the rules and are complying with them too.

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Once the weight loss becomes a public achievement, everyone else gets the message: this is what happens when a woman is disciplined enough to take up less space (Saguy & Gruys, 2010).

I have already gotten into trouble on the internet for objecting to people’s reactions to other people’s weight decisions , and people are already policing one another’s bodies enough that I don’t want to add to the list of things women are expected to do wrong, with everyone watching and judging.

But giving women a break does not require us to cheer every attempt to become smaller. We can respect privacy without pretending that public applause is neutral, because it isn’t, and it’s probably more damaging than people realize.

Talking about diets, calories, and weight loss over and over can help make disordered eating look normal, aspirational, and even instructional. A meta-analysis of 127 studies found that media exposure was associated with body-image concerns and eating-disorder-related outcomes, and that media exposure was especially influential in the internalization of thin ideals (Huang et al., 2021). Another meta-analysis of 32,295 participants found associations between problematic internet use and eating-disorder symptoms, body dissatisfaction, drive for thinness, and dietary restraint (Ioannidis et al., 2021). In an experiment, women exposed to pro-anorexia TikTok content reported lower body-image satisfaction and greater internalization of thinness ideals (Blackburn & Hogg, 2024). A single post is not the whole story. A steady stream of this content can help create a culture in which disordered behavior is easier to learn, praise, and defend.

So when I hear these girls at Pennsic ripping themselves to shreds, I know where they got it from. Wanting to be smaller has almost become a shared female language, and I think it’s time to realize that it’s doing more damage than good.

Even if it isn’t for ourselves, it should be for future generations of girls who are absorbing more information more quickly than they are absorbing calories. I’d ask people who post about weight loss, and the people who reply, to think about the bigger picture.

Celebrating our ability to choose does not require us to celebrate the standards that encourage us to shrink. We can trauma bond over House of the Dragon; we don’t need to trauma bond over being hungry and doing CrossFit.

And, as always, let’s be here for one another in a positive way, uniting against diet culture instead of within it.

References

Blackburn, M. R., & Hogg, R. C. (2024). #ForYou? The impact of pro-ana TikTok content on body image dissatisfaction and internalisation of societal beauty standards. PLOS ONE, 19(8), e0307597. https://doi.org/10.1371/journal.pone.0307597

Huang, Q., Peng, W., & Ahn, S. (2021). When media become the mirror: A meta-analysis on media and body image. Media Psychology, 24(4), 437–489. https://doi.org/10.1080/15213269.2020.1737545

Ioannidis, K., Taylor, C., Holt, L., Brown, K., Löchner, C., Fineberg, N., Corazza, O., Chamberlain, S. R., Román-Urrestarazu, A., & Czabanowska, K. (2021). Problematic usage of the internet and eating disorder and related psychopathology: A multifaceted, systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews, 125, 569–581. https://doi.org/10.1016/j.neubiorev.2021.03.005

Martínez-González, L., Fernández-Villa, T., Molina, A. J., Delgado-Rodríguez, M., & Martín, V. (2020). Incidence of anorexia nervosa in women: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 17(11), 3824. https://doi.org/10.3390/ijerph17113824

Musolino, C., Warin, M., Wade, T., & Gilchrist, P. (2015). Disordered eating and choice in postfeminist spaces. Adelaide Research & Scholarship. http://hdl.handle.net/2440/107598

Riley, S., Evans, A., & Robson, M. (2018). Postfeminism and health. Routledge. https://doi.org/10.4324/9781315648613

Saguy, A. C., & Gruys, K. (2010). Morality and health: News media constructions of overweight and eating disorders. Social Problems, 57(2), 231–250. https://doi.org/10.1525/sp.2010.57.2.231

Medical education continues beyond medical school through residency and, for many doctors, fellowship. Ethics is supposed to be part of that formation, not a decorative paragraph in a handbook (American Medical Association, 2026; Sonntag et al., 2019). When someone holds your life in their hands, you expect them to operate far above the baseline of everyday prejudice: to treat patients fairly, equitably, and strictly by the evidence.

That is why there is an inherent faith built into the phrase “do no harm.” But here is the important correction: “first, do no harm” is not actually in the Hippocratic Oath. The phrase comes from another text in the Hippocratic collection, Of the Epidemics, which says that physicians should “do good or do no harm.” The actual oath contains related promises to benefit patients and avoid deliberate harm, but it does not contain the famous slogan people use to describe it (Shmerling, 2020).

Yet what we have done is turn that idea into a modern promise, one that tells patients they can trust doctors to put their welfare first. In plain terms, it is supposed to mean that before a doctor acts, they have to actually weigh whether their intervention helps or hurts. They are supposed to make sure the care is real and the damage isn’t just brushed off as an acceptable casualty of their own laziness or bias.

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And societally, we hear it the way we hear “protect and serve.” Not as a description of a job, but as a promise. We take those words to mean that the person with authority will use it to protect us, not endanger us; to tell the truth, not manipulate us; to serve our interests, not someone else’s agenda. But, much like “protect and serve ,” do no harm is often misinterpreted.

The phrase “do no harm” is not a legal standard. Even the Hippocratic Oath is not a law or a legally binding contract. Doctors are not sued simply because someone decides they violated the oath. The oath is an ethical promise, a public statement about what medicine is supposed to be, and modern versions vary across schools and professions (American Medical Association, 2026; Radhika, 2019).

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The legal obligation for medical professionals is different. In the United States, a medical malpractice claim generally requires a patient to show that a clinician owed them a duty, breached the applicable standard of care, caused an injury, and left them with damages. The standard is not perfection. It is what a reasonably competent clinician with similar training would have done in the same situation (Bono et al., 2022).

So you cannot walk into court and sue a doctor just for violating some fancy Latin motto. But that ethical principle is what shapes the duties that become legally binding once a doctor takes you on as a patient. The law sets a bare minimum. Ethics demands that doctors stand higher than that baseline, and the American Medical Association explicitly acknowledges that its ethical standards go further than what courts require (American Medical Association, 2026).

In plain language, a doctor does not have to guarantee that they will help you defy death or know exactly how to cure you. A doctor does have to use reasonable care, make decisions for the patient’s welfare, explain material risks and alternatives, respect informed refusals, and avoid letting prejudice replace clinical judgment. A doctor cannot hide behind good intentions after using medical authority to expose a patient to an unreasonable and avoidable risk (American Medical Association, 2026; Sonntag et al., 2019).

We are trained to look for medical harm only when it is catastrophic and undeniable: a botched surgery, a lethal prescription error, the kind of malpractice no one can spin away. But we have been enculturated to think that mistreating fat patients is just normal and reasonable behavior for a doctor, which is why nobody blinks when fat people avoid going to the doctor altogether. We have normalized real, systematic harm against the fat community and refused to hold medical professionals accountable for violating their own creed, their ethics, and their basic responsibilities (Brown & Ellis-Ordway, 2021; Tomiyama et al., 2018).

Two and a half years ago, when Ozempic was brand new, my darlingest friend was at a doctor’s appointment. She was taking metformin for her PMOS and was also breastfeeding. Her doctor got excited about putting her on Ozempic because she was fat. The doctor inquired as to what kind of insurance my friend had, and, upon discovering that it was one that did not cover Ozempic without a diabetes diagnosis, the doctor suggested that she stop taking metformin and essentially try to spike her blood sugar and make herself diabetic so she could qualify for insurance coverage for the drug.

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The doctor seemed far more interested in getting Ozempic approved than in the actual consequences of her plan. The recommendation involved withdrawing a (necessary, prescribed) medication she was taking for PMOS, putting a diabetes diagnosis in her chart, and offering semaglutide to someone who was breastfeeding.

For which there is no data on safety. To say that it was an irresponsible suggestion is an understatement. The FDA labeling says there are no data on semaglutide in human milk, effects on breastfed infants, or effects on milk production. Animal data are not reassuring either: in lactating rats, semaglutide was detected in milk at levels three to twelve times lower than in maternal plasma. The FDA says the clinical relevance to humans is unclear, but unclear is not the same thing as safe. A small 2024 study of eight breastfeeding women found no measurable semaglutide in their milk, but it could not answer the long-term questions about infant outcomes, maternal nutrition, or breast milk composition (United States Food and Drug Administration, 2025; Diab et al., 2024).

This desperate, reckless push to get fat people on Ozempic at literally all costs is not a one-off. As I’ve written about elsewhere, doctors are routinely willing to falsify diagnoses or look the other way while patients face severe repercussions, all to secure a prescription in the name of weight loss (that is not even guaranteed).

But the reality is that my friend’s story is in no way unique. Every fat person has a doctor story. The doctor who was cruel. The doctor who was frightening. The doctor who made a recommendation so reckless you wondered whether they had ever met a fat person before. Or at the very least, whether that fat person survived the encounter.

Cultural fatphobia has bred a pervasive medical sloppiness across the board, turning lazy assumptions into standard operating procedure when it comes to medical care.

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It seems as though medical ethics aren’t immune from being thinned too.

It’s not even limited to the doctor themselves, either. Sometimes the story is the equipment. A blood-pressure cuff that does not fit, a scale that cannot accommodate your body, or an exam table, gown, chair, or MRI machine built around the assumption that everyone who needs care is small (Shanouda, 2021). Here we laugh about the humiliation ritual of a gown that does not close and our big exposed asses, but it goes deeper and is more harmful than that.

Inadequate medical equipment interferes with accurate measurement, physical examination, diagnostic imaging, and basic access to care. Even the U.S. Department of Health and Human Services (HHS) has recognized inaccessible examination tables and weight scales as barriers that can exclude people with disabilities from basic health services (U.S. Department of Health and Human Services, 2024).

Proper medical care is also supposed to entail a thorough workup: careful history-taking, appropriate diagnostic testing, and investigating symptoms on their own terms. Instead, what fat patients get is a diagnostic dead end. Symptoms are routinely dismissed or attributed entirely to weight, leading to fewer diagnostic tests and delayed or avoided care after stigmatizing encounters (Tomiyama et al., 2018).

I’ve written before about the extreme amount of fatphobia that medical students report before they’ve even had any medical training, but one has to wonder that, if someone believes you are actively “not caring” for yourself by being fat, that their resulting lack of care of you is really an accident.

And, when it extends to critical life-saving measures, like organ transplants , it has the ability to literally kill the fat people these doctors are charged with taking care of.

These moments expose how cultural disgust toward fat bodies translates into active medical abandonment.

Institutional weight thresholds and arbitrary BMI cutoffs for necessary surgeries pretend to be objective safety metrics, but they function as a license to decide that certain people are simply not worth operating on, not worth saving, and not entitled to live, despite a lack of evidence supporting strict cutoffs as valid clinical barriers (Lassalle et al., 2017; Krishnan et al., 2015; Ricciardi et al., 2019; Tomiyama et al., 2018).

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And it is impacting fat people at every level and stage of medical care.

As a woman with lipedema, I have large upper arms. When I go to the doctor, the standard automatic blood pressure machine cuff squeezes me so tightly it hurts, bringing me to tears. The machine logs a high reading. Because I am fat, and high blood pressure is treated as an inevitable fat disease, the clinician immediately records it as hypertension.

I don’t have hypertension, as evidenced by the fact that when I have my blood pressure taken manually, or with the wrist cuff (which is not impacted by lipedema), my blood pressure is actually on the low side. Yet every time I get my blood pressure taken, I literally have to monologue while they look at me like I am full of shit because of course I must have high blood pressure because I am fat. I am being pigeonholed into a false diagnostic narrative simply because the clinic’s tools are built for someone else. Someone smaller.

When you look at the totality of it, fatphobia has completely eroded any recognizable standard of care for fat patients. Because our bodies are presumed to be an ongoing pathology, we receive half-assed care at best and active rejections from lifesaving treatments at worst.

We are peddled dangerous, short-sighted drugs in the name of weight loss (a historical repetition we have seen before with disasters like Fen-phen) and told that thinness is the sole path to health , a claim backed by neither medicine, science, nor objective evidence (Bacon & Aphramor, 2011; Flegal et al., 2013; Tomiyama et al., 2016).

This isn’t just sloppy medicine or silly TikTok storytimes. At a certain point, we have to ask whether we’ve crossed squarely into medical malpractice territory. When clinicians refuse to investigate real symptoms, rely on non-inclusive equipment, and push dangerous interventions just to try to shrink a body, they are breaching their fundamental duty of care.

And the damage doesn’t even stop when you walk out of the clinic doors or avoid them entirely. Medical bias and stigma inflict profound harm on the fat community simply by keeping people away from the doctor altogether (Brown et al., 2022; Puhl & Heuer, 2010; Tomiyama et al., 2018).

I have yet to find a primary care doctor after my disastrous experience last month .

And I’m not alone.

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Millions of fat people delay or completely avoid seeking care because they know the visit will be an exercise in humiliation, where every real symptom is blamed on their weight and every boundary is treated as ”noncompliance” (Brown et al., 2022; Puhl & Heuer, 2010). The fear of being judged, dismissed, or actively harmed by the people holding the prescription pad is driving a wedge between fat people and the healthcare they need.

We already know people need protection from the medical system. That’s why we have laws like Section 504 of the Rehabilitation Act to protect disabled patients from being discriminated against or turned away (U.S. Department of Health and Human Services, 2024; 45 CFR § 84.56).

But when it comes to weight, there are virtually no legal protections at all. The cultural script is that if you hate going to the doctor, it is simply because you do not want to be told you are fat, and since doctors supposedly know best, any mistreatment you encounter is written off as deserved scolding (Puhl & Heuer, 2010; Tomiyama et al., 2018).

We have been conditioned to believe that we deserve whatever mistreatment we get in a doctor’s office, as if poor care is just the inevitable tax for existing in a fat body.

But we don’t.

Society has elevated doctors to an untouchable status where they automatically ‘know best,’ without ever holding them responsible for actually doing the work to know best. Unless medicine is going to live up to its own standards, its ethics, and its oaths, we need to completely reevaluate why we give them our blind faith in the first place (American Medical Association, 2026; Bono et al., 2022).

The idea of the “standard of care” also raises an obvious question. If fatphobia is part of the profession’s baseline, how is a fat patient supposed to prove that another “reasonably competent clinician” would have done anything differently? If the comparison group is just as likely to dismiss symptoms, use the wrong equipment, or treat weight loss as the only answer, the standard can turn systemic bias into the definition of competent care (Brown et al., 2022; Tomiyama et al., 2018).

But power isn’t just held by the person in the white coat. It is also shaped by what we are willing to accept. We have power, and we have to use it.

Stop apologizing, stop carrying the shame in isolation, and stop accepting substandard care as the price of admission. GET ANGRY. PUSH BACK. When a clinician weaponizes your body size against you instead of investigating your actual symptoms, demand the real data, reject their lazy shortcuts, and walk out.

Stop treating our survival as a private problem and start demanding the exact standard of care that medicine already requires and promises (Brown et al., 2022; Puhl & Heuer, 2010).

Maybe it’s time to modify our expectations from Do No Harm to Take No Shit.

References

American Medical Association. (2026). AMA Principles of Medical Ethics. https://code-medical-ethics.ama-assn.org/principles

Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10, 9. https://doi.org/10.1186/1475-2891-10-9

Bono, M. J., Wermuth, H. R., & Hipskind, J. E. (2022). Medical malpractice. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470573/

Brown, A., Flint, S. W., & Batterham, R. L. (2022). Pervasiveness, impact and implications of weight stigma. EClinicalMedicine, 47, 101408. https://doi.org/10.1016/j.eclinm.2022.101408

Brown, H. A., & Ellis-Ordway, N. (2021). Weight bias in health education: Critical perspectives for pedagogy and practice. Routledge.

Diab, H., Fuquay, T., Datta, P., Bickel, U., Thompson, J. E., & Krutsch, K. (2024). Subcutaneous semaglutide during breastfeeding: Infant safety regarding drug transfer into human milk. Nutrients, 16(17), 2886. https://doi.org/10.3390/nu16172886

Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA, 309(1), 71–82. https://doi.org/10.1001/jama.2012.113905

Krishnan, N., Higgins, R., & Bannister, K. M. (2015). Kidney transplantation significantly improves patient and graft survival irrespective of BMI. American Journal of Transplantation, 15(8), 2095–2102. https://doi.org/10.1111/ajt.13363

Lassalle, M., Fezeu, L., Couchoud, C., Hannedouche, T., Massy, Z. A., & Czernichow, S. (2017). Obesity and access to kidney transplantation in patients starting dialysis: A prospective cohort study. PLoS ONE, 12(5), e0176616. https://doi.org/10.1371/journal.pone.0176616

Legal Information Institute. (n.d.). Negligent tort. Cornell Law School. https://www.law.cornell.edu/wex/negligent_tort

Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: Important considerations for public health. American Journal of Public Health, 100(6), 1019–1028. https://doi.org/10.2105/AJPH.2009.159491

Radhika, M. S. (2019). Hippocratic oath: Losing relevance in today’s world? Indian Journal of Psychiatry, 61(Suppl 4), S773–S775. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_140_19

Ricciardi, B. F., Giori, N. J., & Fehring, T. K. (2019). Clinical faceoff: Should orthopaedic surgeons have strict BMI cutoffs for performing primary TKA and THA? Clinical Orthopaedics and Related Research, 477(12), 2605–2608. https://doi.org/10.1097/CORR.0000000000001017

Shmerling, R. H. (2020, June 22). First, do no harm. Harvard Health Publishing. https://www.health.harvard.edu/blog/first-do-no-harm-201510138421

Shanouda, F. (2021). Medical equipment. In H. A. Brown & N. Ellis-Ordway (Eds.), Weight bias in health education: Critical perspectives for pedagogy and practice (pp. 30–42). Routledge.

Sonntag, E. A., Shah, K. B., & Katz, J. N. (2019). Educating resident and fellow physicians on the ethics of mechanical circulatory support. AMA Journal of Ethics, 21(5), E407–E415. https://doi.org/10.1001/amajethics.2019.407

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, 123. https://doi.org/10.1186/s12916-018-1116-5

Tomiyama, A. J., Hunger, J. M., Nguyen-Cuu, J., & Wells, C. (2016). Misclassification of cardiometabolic health when using body mass index categories in NHANES 2005–2012. International Journal of Obesity, 40(5), 883–886. https://doi.org/10.1038/ijo.2016.17

U.S. Department of Health and Human Services. (2024a). Section 504 of the Rehabilitation Act of 1973: Part 84 final rule fact sheet. https://www.hhs.gov/civil-rights/for-individuals/disability/section-504-rehabilitation-act-of-1973/part-84-final-rule-fact-sheet/index.html

U.S. Department of Health and Human Services. (2024b). 45 CFR § 84.56: Medical treatment. https://www.law.cornell.edu/cfr/text/45/84.56

Yüksel, S., Altun-Uğraş, G., Altınok, N., & Demir, N. (2020). The effect of cuff size on blood pressure measurement in obese surgical patients: A prospective crossover clinical trial. Florence Nightingale Journal of Nursing, 28(2), 205–212. https://doi.org/10.5152/FNJN.2020.19119

Maybe someone skeletal. Maybe someone so thin you can count their ribs. Given the cultural standards these days, maybe not.

I think most people picture some degree of emaciation. But fewer than 6% of people diagnosed with eating disorders are medically underweight (Flament et al., 2015). The vast majority live in bodies that are normal-weight, overweight, or even obese. That number should change how you think about what an eating disorder looks like, because the body you are picturing is the exception, not the rule.

The behaviors that define eating disorders: restriction, food fear, compulsive exercise, moralizing every bite, happen in every size body. Whether anyone calls it an eating disorder depends less on what the person is doing and more on what they look like while doing it.

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And right now, the culture is doing everything it can to make sure you never notice.

Celebrity magazines run “what I eat in a day” features right next to “what’s in my bag,” as though what someone puts in their stomach is as benign in its messaging as what they carry in their purse.

It isn’t. One is a shopping list. The other is a blueprint for restriction that readers will copy by Tuesday.

And when a celebrity drops a dramatic amount of weight, the machinery kicks into gear. Every outlet runs the “how she did it” breakdown. What she eats for breakfast, what she cut out. What trainer she calls. The weight loss is the headline. The method is the recipe. The question of whether any of it was safe or disordered is never the story

TikTok and Instagram and YouTube do the same thing at scale because they are available even to us, the plebes. Normal women filming every meal, every snack, every workout, narrating it in the language of wellness and self-care. The comments call it inspiration. They call it goals. But look closer at what is actually being celebrated: a woman who wakes up at 5am to exercise, drinks a green juice for breakfast, eats a salad for lunch, has a protein bar as a snack, and calls it a full day of eating. That’s not thinspo or fitspo or any kind of good ‘spo. That’s a checklist of disordered behaviors dressed up in lululemon with aesthetic lighting and a good soundtrack.

And none of this is hidden. It is not tucked into proAna forums or buried in the dark corners of the internet. It is the main feed. The algorithm does not care whether the content promotes health or harm. It cares whether you watch. And restriction, filmed beautifully, keeps people watching.

Culture has figured out how to sell restriction as a lifestyle . It doesn’t matter whether you call it intermittent fasting, clean eating, or getting on top of your health. The body doesn’t know the difference. It knows that it’s not getting enough nutrition, and it can’t hear the catchy music that goes along with it.

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A really skinny person skips meals and people get concerned. A slightly less skinny person, not EVEN a fat person, skips meals and they get praised for their commitment. The behavior is identical. Only the body changes, and with it, the story we tell about what the behavior means.

That is the visibility problem. We have been trained to recognize eating disorders by sight, as though they come with a required body type. Anorexia means emaciated. Bulimia means thin with bad teeth. Binge eating disorder means a fat person with no self-control. Those images are not just reductive, they are statistically wrong. And because we are looking for a body instead of a behavior, we miss the behavior in every body that doesn’t match the picture.

I think about the people I know who count every calorie but call it “being disciplined.” Who skip lunch but say they’re “just not hungry.” Who exercise through injury because rest feels like failure or sloth. Who wake up at 5am because working out from 5 to 9 is a normal accompaniment to their 9 to 5. Who apologize for eating in front of other people. Who track their macros with the same obsessive precision they’d apply to a bank account. Who have not had a normal relationship with food since they were eleven years old and have no idea that it’s weird because everyone around them is doing the same thing.

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These are not edge cases. These are the habits of millions of people who will never meet the criteria for an eating disorder diagnosis because the culture has decided that what they’re doing is health.

And the behaviors do not stay stable. They escalate. Calorie counting becomes obsession, running becomes punishment, food rules become walls you cannot climb over. There is no bright line where discipline ends and disorder begins, just a slow accumulation of rules that tighten until you cannot remember what it felt like to eat without thinking about it.

Eating disorders are the deadliest mental illness there is. They kill more people than any other psychiatric condition. People die from cardiac arrest when their heart muscle wastes away.

Mama Cass died at 33 of a heart attack, and no one would have ever accused her of having an eating disorder, but she’d been put on amphetamines by a doctor when she was eight years old in order to lose weight (Elliot-Kugell, 2024). She spent decades crash dieting, losing over a hundred pounds in one stretch and landing in the hospital for it. The yo-yo of starving and regaining stripped her heart of the muscle it needed to keep going.

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Eating disorders kill people biologically and mentally; from organ failure, from suicide. And the longer the behaviors go unnamed, the harder recovery becomes. Some people run out of time before anyone thought to even notice that disordered eating had become “too serious.”

The diagnosis requires a psychological dimension that culture has conveniently made invisible. You can restrict, fear food, exercise compulsively, and moralize every bite, and no one will call it what it is, as long as your body doesn’t look the part. The clinical criteria exist. The treatments exist. What doesn’t exist is a culture willing to name the behavior before it becomes a crisis.

Don’t just assume because you’re not crying that the size 00 is too big for you that you don’t have an eating disorder. Start realizing how insipid the language is that we have normalized around fueling and nourishing our bodies.

We owe it to ourselves to stop saying “I was so bad” when we ate something we enjoyed. To stop calling food “guilty pleasures.” To stop treating hunger like an illness. To stop applauding weight loss, no matter the context. That language isn’t harmless. It’s the same language clinical eating disorders are built on, and every time we use it, we make it harder for someone to realize that they’ve gone too far and are endangering themselves.

References

Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731. https://doi.org/10.1001/archgenpsychiatry.2011.74

Elliot-Kugell, O. (2024). My Mama, Cass: A memoir. Hachette Books.

Flament, M. F., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H. N. L., Musso, L., Bhatt, M., & Goldfield, G. (2015). Weight status and DSM-5 diagnoses of eating disorders in adolescents from the community. Journal of the American Academy of Child & Adolescent Psychiatry, 54(5), 389-394. https://doi.org/10.1016/j.jaac.2015.01.020

Weight loss advertising does not only target fat people, as far as I am aware. It targets anyone with a body, which is to say everyone, as a potential customer for the message that something about them needs to be corrected. Platforms identify you as fat and then hit you with a constant barrage of messaging insisting that of course you want pharmaceutical intervention . Of course you do. If there is one thing that capitalism teaches us at the end of the day, consent costs extra.

Weight loss ads are, of course, big business, but the scale and acceleration should be staggering. Drugmakers spent more than $1 billion on ads for weight loss and diabetes medicines in 2023 alone, up more than 50% from the prior year (CNBC, 2024). By 2025, GLP-1 drug advertising on national TV alone had exceeded $1.1 billion, nearly one-fifth of all pharmaceutical linear TV spending (EMARKETER, 2026). Twenty percent of all pharmacy ad spending was spent on GLP-1s.

Not for cancer. Not for heart disease. For weight loss. At their peak, Viagra and Cialis combined spent roughly $500 million a year on advertising. The only thing getting supersized these days is spending; weight loss drugs now spend more than double that, and, unlike your penis, they are not done growing. The cultural slot that boner pills used to occupy has been taken over by drugs that promise something more insidious than better sex. They promise a different body.

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What makes weight loss messaging different from other forms of ubiquitous advertising is that it does not only sell a product. It sells a problem, and the problem is you. You do not need to have searched for ways to lose weight. You do not even need to be significantly fat. You just need to exist in a body that an algorithm has flagged as a conversion opportunity, because every weight loss ad carries the same implicit premise: your body is not acceptable, and it needs monitoring.

The threat of obesity mobilizes self-regulation and self-surveillance in individuals regardless of actual body size (Saguy, 2013). When shame activates, people move into one of four scripts described in the Compass of Shame (Nathanson, 1992): they withdraw, they avoid, they redirect the shame outward, or they turn it on themselves. Weight loss advertising is designed to trigger that fourth one.

Weight loss advertising triggers that shame across every body type. That shame can turn inward, becoming the self-surveillance and self-punishment that the diet industry calls a wellness journey. But it can also turn outward, becoming the judgment and body policing that we direct at other bodies to manage our own discomfort.

Because when your body is treated as something to be judged, you learn to judge it too. Psychologists call this objectification theory (Fredrickson & Roberts, 1997). Your brain doesn’t process these ads as sales pitches. It processes them as social comparisons, without you even noticing (Tiggemann & McGill, 2004). And the harm shows up in the clinical data: body surveillance, internalized weight bias, and body shame predict eating pathology severity (Martin-Wagar & Weigold, 2022).

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So what does that even mean?

It means that every ad you see changes how you relate to your own body. You start watching yourself from the outside, monitoring how you look, treating your appearance as something to manage and control. You internalize the message that your body is wrong, and you carry that message into every room you walk into. Over time, that monitoring becomes a permanent state. It changes what you eat, how you move, whether you leave the house, how you feel about yourself when no one is looking.

And then your body responds to all of that. The shame triggers a physiological stress response that increases cortisol, which promotes appetite and fat storage, which produces more shame, which triggers more stress (Himmelstein et al., 2015). Rinse. Repeat.

Weight stigma is positively associated with obesity and diabetes risk, increased oxidative stress, and C-reactive protein levels, no matter how much you do or don’t weigh (Wu & Berry, 2017). The psychological and physiological damage compound each other, and they compound over time.

If weight loss ads are meant to produce shame, and that shame is meant to produce weight loss, why should we be upset about weight loss ads?

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Tomiyama et al. (2018) documented that shame does not produce the weight loss the way we have been taught to believe, and it is instead associated with psychological distress, disordered eating, avoidance behaviors, and poorer health outcomes rather than sustained positive change. And the cruelest dimension is that the shame is internalized as personal failure.

Every ad is reaffirming that your body is wrong, and that it needs all of this extra surveillance and management and control. And PRODUCTS, of course. You internalize the message that the problem lives inside your own skin, and you detach yourself from your body. And when that happens, you stop trusting your body. You don’t trust your hunger, you don’t trust your signals.

Eating disorders researchers have argued that eating disorders are not just psychiatric conditions but culturally-induced diseases promoted partly by economic and social institutions that profit from the cult of thinness promoted by the mass media (Hesse-Biber et al., 2006). They have documented a lucrative market associated with eating disorders, and the advertising, weight-loss, diet-food, fitness, and cosmetic surgery industries are well aware of it.

A survey by the UK eating disorder charity Beat found that 96% of people with eating disorder experience found online weight loss ads harmful to their recovery (Beat, 2022). Not some people. Not many. Almost all.

And the people designing these campaigns know exactly what they are doing. Gak et al. (2022) describe targeted weight loss advertising as a form of slow violence: harm that is dispersed across time and space, that accumulates through repeated exposure rather than a single event, and that disproportionately affects those already marginalized. The ads do not need to be overtly cruel. They just need to be constant.

The violence is in the repetition.

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So if weight loss advertising is so bad for people, why isn’t anyone doing anything to curtail them?

Platforms themselves have already written policies that should, by their own language, prohibit most weight loss advertising. The rules exist. They are just not enforced against the industry that most clearly violates them.

Meta prohibits advertisers from running ads that imply or attempt to generate negative self-perception in order to promote diet, weight loss, or other health-related products (Meta, 2024). Their policy explicitly bans ads that exploit insecurities to conform to certain beauty standards, reinforce negative or unhealthy body images, feature body-shaming, use distasteful messaging that could make people feel negatively about the way they look, or show side-by-side before-and-after comparisons for weight loss.

Under Meta’s own rules, a weight loss ad that makes you feel bad about your body should not exist on their platform. And yet.

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TikTok’s advertising policies state that ad content and landing pages must not explicitly shame users about their bodies, suggest there is an ideal body type, or promote improved life circumstances or self-image as a result of changes in body appearance or weight (TikTok, 2026). They further ban content that suggests there is a right or perfect way to look, claims that looking a certain way will make individuals more desirable, successful, happy, or popular, or suggests that body appearance determines a person’s confidence, self-esteem, emotional wellbeing, desirability, popularity, or social standing.

Under TikTok’s own rules, an ad promising that weight loss will make you happier, more confident, or more successful should not exist on their platform. And yet.

Pinterest went further than any other platform. In July 2021, it became the first major platform to ban all weight loss advertising outright, prohibiting any weight loss language or imagery, any testimonials regarding weight loss or weight loss products, any language or imagery that idealizes or denigrates certain body types, and referencing Body Mass Index or similar indexes (Pinterest, 2021). The policy was developed with guidance from the National Eating Disorders Association, whose then-interim CEO called it a necessary step in prioritizing the mental health and well-being of Pinners, especially those impacted by diet culture, body shaming, and eating disorders.

Pinterest demonstrated that it is technically and operationally possible for a major platform to simply ban weight loss ads. They rejected over 4.2 million ads for body image policy violations in the second half of 2025 alone and removed 1.8 million organic pins for body shaming content (AuditSocials, 2026). The infrastructure to enforce such a ban exists. The precedent exists. The other platforms simply choose not to follow it.

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The UK’s Advertising Standards Authority, working with the Medicines and Healthcare products Regulatory Agency, issued an enforcement notice in 2025 specifically targeting online advertising of weight loss drugs, reinforcing rules that require such products to be marketed responsibly and through appropriate channels (ASA, 2025).

Let us be explicit about this, because the disconnect between what platform policies say and what they permit is not a technical failure. It is a choice.

Meta bans ads that imply or attempt to generate negative self-perception to sell health products. Every weight loss ad implies that your current body is a problem to be fixed. That is the entire premise. Without the negative self-perception, there is no product to sell.

TikTok bans ads that suggest there is an ideal body type or claim that body appearance determines a person’s confidence, happiness, success, etc etc etc etc, you know the schpiel. Every weight loss ad, by definition, suggests that a different body type would produce a better life. The before-and-after format is not incidental to diet advertising. It is the core persuasive structure: this body was bad, this body is good, and the product is the bridge between them.

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TikTok also bans content that promotes disordered eating and risky weight management behaviors. The diet industry’s foundational product is caloric restriction. The average diet involves severe calorie reduction that most nutritional science identifies as unsustainable and counterproductive. The UCLA meta-analysis found that at least one-third to two-thirds of people on diets regain more weight than they lost within four or five years (UCLA Newsroom, 2007). The annual probability of an obese woman achieving “normal weight” is 1 in 124 (Fildes et al., 2015).

If a product failed this consistently in any other industry, the FTC would call it deceptive. In the weight loss industry, it is called a business model.

Weight loss ads are, by their very nature, deceptive and toxic. They promise outcomes that decades of research say are largely impossible to sustain. They are damaging and constant. They produce shame, self-surveillance, and disordered eating in the people who see them, and that shame does not stay contained. The research is clear that this contributes to a larger epidemic of shame and body hatred that extends far beyond dieting. The ads are not a side effect of that epidemic. They are the engine.

The rules to stop weight loss ads already exist. Every major platform has written policies that should prohibit most weight loss advertising. Pinterest proved a platform can enforce them. The question is why we continue to treat the diet industry as an exception to rules that every other industry must follow , and whether the answer has anything to do with the seventy billion dollars it generates.

References

ASA. (2025, September). ASA partners with MHRA and GPhC to reinforce rules on the advertising of weight-loss drugs online. Advertising Standards Authority. https://www.asa.org.uk/news/asa-partners-with-mhra-and-gphc-to-reinforce-rules-on-the-advertising-of-weight-loss-drugs-online.html

AuditSocials. (2026, April 15). Pinterest ads 2026: Weight loss ban and wellness rules. https://www.auditsocials.com/blog/pinterest-ads-policy-2026-weight-loss-body-image-wellness-content-restrictions

Beat. (2022). Online advertising and eating disorders. Beat Eating Disorders. https://www.beateatingdisorders.org.uk/get-information-and-support/about-eating-disorders/research/online-advertising-and-eating-disorders/

Saguy, A. C. (2013). What’s wrong with fat? The war on obesity and its collateral damage. Oxford University Press.

CNBC. (2024, April 3). Weight loss, diabetes drug ad spending tops $1 billion. https://www.cnbc.com/2024/04/03/weight-loss-diabetes-drug-ad-spending-tops-1-billion.html

EMARKETER. (2026, May 7). Novo and Lilly face a GLP-1 pill marketing showdown. https://www.emarketer.com/content/weight-loss-drugmakers-top-sales-forecasts-pill-rivalry-intensifies

Federal Trade Commission. (2002). Weight loss advertising: An analysis of current trends. U.S. Federal Trade Commission. https://search.ftc.gov/sites/default/files/documents/reports/weight-loss-advertisingan-analysis-current-trends/weightloss_0.pdf

Fildes, A., Charlton, J., Rudisill, C., Littlejohn, C., Bilston, L. E., & Griffin, S. (2015). Probability of an obese person attaining normal weight: A meta-analysis. American Journal of Public Health, 105(9), e54-e56. https://doi.org/10.2105/AJPH.2015.302773

Fredrickson, B. L., & Roberts, T.-A. (1997). Objectification theory: Toward understanding women’s lived experiences and mental health risks. Psychology of Women Quarterly, 21, 173-206.

Gak, L., Olojo, S., & Salehi, N. (2022). The distressing ads that persist: Uncovering the harms of targeted weight-loss ads among users with histories of disordered eating. Proceedings of the ACM on Human-Computer Interaction, 6(CSCW2), Article 377. https://doi.org/10.1145/3555102

Hesse-Biber, S. N., Leavy, P., Quinn, C. E., & Zoino, J. (2006). The mass marketing of disordered eating and eating disorders: The social psychology of women, thinness and culture. Women’s Studies International Forum, 29, 208-224. https://doi.org/10.1016/j.wsif.2006.03.007

Himmelstein, M. S., Incollingo Belsky, A. C., & Tomiyama, A. J. (2015). The weight of stigma: Cortisol reactivity to manipulated weight stigma. Obesity, 23(2), 368-374. https://doi.org/10.1002/oby.20959

Martin-Wagar, C. A., & Weigold, I. K. (2022). Internalized stigma as a transdiagnostic factor for women with eating disorders. Eating Disorders: The Journal of Treatment & Prevention, 30(5), 495-510. https://doi.org/10.1080/10640266.2022.2095481

Meta. (2024, December 26). Health and wellness. Meta Transparency Center. https://transparency.meta.com/policies/ad-standards/restricted-goods-services/health-wellness/

Nathanson, D. L. (1992). Shame and pride: Affect, sex, and the birth of the self. W. W. Norton.

Pinterest. (2021, July 1). Pinterest embraces body acceptance with new ad policy. Pinterest Newsroom. https://newsroom-archive.pinterest.com/pinterest-embraces-body-acceptance-with-new-ad-policy

Pinterest. (2025, February). Advertising guidelines. Pinterest Policy. https://policy.pinterest.com/en/advertising-guidelines

Reuters. (2026, January 28). Novo’s Wegovy and Ozempic US advertising spend doubles rival Eli Lilly, data shows. https://www.reuters.com/business/media-telecom/novos-wegovy-ozempic-us-advertising-spend-doubles-rival-eli-lilly-data-shows-2026-01-28/

TikTok. (2026, June). Weight management and body image. TikTok Advertising Policies. https://ads.tiktok.com/help/article/tiktok-ads-policy-weight-management

Tiggemann, M., & McGill, B. (2004). The role of social comparison in the effect of magazine advertisements on women’s mood and body dissatisfaction. Journal of Social and Clinical Psychology, 23(1), 23-44.

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, 123. https://doi.org/10.1186/s12916-018-1116-5

UCLA Newsroom. (2007, April 3). Dieting does not work, UCLA researchers report. UCLA Newsroom. https://newsroom.ucla.edu/releases/Dieting-Does-Not-Work-UCLA-Researchers-7832

Wu, Y. K., & Berry, D. C. (2017). Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. Journal of Advanced Nursing, 73(5), 1031-1044.

I was 17 and I lived in New York, in Manhattan, and, for the first summer ever, I had a boyfriend. His family lived in Howard Beach (which is in Queens) and they belonged to a beach club.

I lived on the Upper West Side, and, in the 1990s, there was a weirdly limited number of places to buy bathing suits at all, but there was this specialty “luxury” bathing suit store near my house called the Town Shop , which, unbelievably, still exists today. So I set out to get my very first bikini.

I was concerned because I wasn’t sure I could find one that would fit me.

I ended up finding a bikini that had a string top and sort of a fuller bottom that had a skirt, which was good for me, because I felt like my bottom half was the one that was probably the most problematic (thanks, lipedema).

Did I feel comfortable at the beach club? Absolutely not, but it is interesting to me in retrospect that it took me having my first serious boyfriend (and first serious sex) to feel like it was “okay” for me to have a bikini. Of course, at 17, I was probably barely a size 14, but for the 1990s, I was huge. Even Kate Winslet was fat in 1997.

What I didn’t understand at 17, but understand now, is that the boyfriend wasn’t just a boyfriend. He was a voucher. Proof that my body was desirable enough to be chosen. And if it was desirable enough to be chosen, it must be acceptable enough to be seen in public (Bien et al., 2026).

Research backs this up. Body acceptance from a romantic partner is positively associated with how women perceive their own sexual attractiveness and physical condition (Bien et al., 2026). A 2020 study even developed a scale measuring how you believe your partner feels about your appearance as a distinct component of body image in relationships (Brederecke et al., 2020). The boyfriend didn’t just want me. He saw me. And because he saw me and still wanted me, I believed I was allowed to exist in public, in a bikini.

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But here’s the thing. Even positive appearance feedback from a partner can reinforce the idea that your body’s value depends on someone else’s desire. Calogero and colleagues called this “complimentary weightism,” where complimenting someone’s appearance feels harmless but actually makes them more likely to evaluate themselves through someone else’s eyes (Calogero et al., 2009). I wasn’t free from diet culture or the Bikini Police. I was just granted a temporary stay of execution.

Weirdly, as I got older (and bigger), I stopped seeking out bikinis.

I’ve talked a lot about the performances that we all execute in order to fit into the social rules around us, and one of those things as a fat person is to make sure that the skinny people around you know that YOU know that it’s not okay to be fat. And in my twenties, I had this sort of go-to joke about how “just because they sell the bikini in a large doesn’t mean you should BUY it in a large!” and then I would laugh, not just at the expense of fat bodies, but at myself.

I remember performing this act of self deprecation in front of my friend, who was pretty and skinny, and also not originally born in America. And I remember her look of horror and dismissal as she replied “Who the fuck cares? If you want to wear a bikini, just wear one.”

I recall being sort of shocked and embarrassed and confused and hurt. Here I was, fully believing that I was doing the proper thing in dissing fat ladies in bikinis, and here was my friend, telling me (rightfully) that I was being an asshole.

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I was being an asshole, and fat people aren’t the only ones doing it, but it’s one of the mechanisms that keeps fatphobia chugging along. Research on internalized weight stigma identifies a process called self-application of negative stereotypes, where people absorb societal stigma and adopt socially acceptable personas to manage how others see them (Nagy et al., 2025). The jokes I made were exactly that.

People in marginalized bodies learn to manage their appearance in ways that minimize the threat they pose to others, and this kind of impression management is a documented survival strategy (Thomas et al., 2021). It is referred to as respectability politics, the idea that marginalized groups police their own members in order to gain acceptance from the dominant group (Jefferson, 2019). Whether or not that dominant group is in a bikini.

The Bikini Police is a particularly menacing regulatory body because, the reality is, there really ISN’T a metric for what the “perfect” bikini body is. The percentage of women who have that sort of Sports Illustrated swimsuit model perfection is so miniscule, particularly when you remove the requisite airbrushing.

Research shows that 66% of professional fashion models are underweight, with one-quarter having a BMI below the clinical cutoff for anorexia (despite the BMI being a steaming pile of doggie doodoo ), and professional models weigh on average 23% less than the average woman (Park, 2017). A 2026 analysis of nearly 800,000 modeling records found that despite increasing “diversity” in fashion media, the median model physique has barely changed in 25 years (Boucherie et al., 2026). And that is before you factor in the airbrushing. Professional retouchers have confirmed that 100% of fashion magazine images are digitally altered, with bodies slimmed, skin smoothed, and proportions rearranged to create a standard that does not exist in nature (Glamour, 2012).

So the ideal bikini body is … maybe not even real.

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And yet it is the universally accepted standard by which we judge ourselves!

Think about the times you have denied yourself a bikini, even in theory. Or the reasons you have though unequivocally that someone else “shouldn’t” be wearing a bikini. They didn’t have a flat stomach. Their breasts were too small. Their breasts were too big. Their breasts were too far apart. They didn’t have a flat ass. They didn’t have a round ass. They had hip dips. They didn’t have a cinched waist. I could probably go on and on, but no one likes a CVS receipt.

So many fucking ads and campaigns and social messaging are around having the perfect bikini body but in reality, perfect for whom?!

Or is it just another unmeasured, unmeasurable goal to keep us running on that treadmill, physically and metaphorically.

We may not know what the perfect bikini body is, but gosh do we feel justified in deciding what isn’t a perfect bikini body.

I took a mermaid class at the Chinquapin Park Recreation Center last year. The Center has explicit rules against wearing thongs, but I think we all know what a thong bathing suit is.

No, not this.

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I wore a string bikini to one of my first mermaid classes, not a thong, but uhh, I have lipedema and I have what has been described as a “gigabutt” and the fabric that covers your ass is likely going to cover a lot less of my ass.

And a lifeguard came over, and told me that I should “probably wear a different bathing suit” because “there were children present.”

Children being present!?! To my fat ass!??

I don’t have to look far into the puritanical guidebook to find the idea that fat bodies are sexual, dangerous, inappropriate for children to see. The philosopher and legal scholar Janet Halley called this “governing through the children,” the idea that the presence of children is used as a moral trump card to justify exclusion and shame (Halley, 2006). When someone tells you that your body is inappropriate “for children,” they are protecting a norm, not children.

The bar for what an “appropriate” bathing suit is has moved substantially over the years, but I’m not under the delusion that the commentary I got had anything to do with my actual swimsuit.

Fat studies scholars have written about how public spaces for exercise and recreation are “discursively and concretely constructed as exclusive spaces for the normative bodied” (Harjunen, 2019). That lifeguard was enforcing a boundary, not a dress code. The message was clear: this space is not for you.

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And that’s what we do to one another when, in our fear of the Bikini Police, we become the Bikini Police.

Sociologists have described this kind of systemic shame as a form of “disciplinary power,” a way of keeping people in line through ongoing surveillance and judgment, a process that is both personal and institutional (Creed et al., 2014). The shame I felt at that pool was manufactured and designed by the shame that lifeguard felt for her own body. The compass of shame, pointing right at me, true north, and my fat ass.

Considering that the “perfect bikini body” doesn’t exist, maybe that’s not an accident. Maybe the impossibility of the ideal is the point. Because as long as we are all chasing something that doesn’t exist, we are all too busy running to stop and ask who benefits from the race.

Or from the police. And the realization that, without us being in the Bikini Police, there would be no Bikini Police.

Consider this my resignation letter. Effective immediately, I am retiring from the Bikini Police. I’m hanging up my holstered sunscreen and turning in my badge. Me and my ass will be at the pool.

References

Bien, M. J., et al. (2026). Partner acceptance and body image: How romantic relationships shape women’s perceptions of their own bodies. Journal of Clinical Medicine, 15(10), 3562. https://doi.org/10.3390/jcm15103562

Boucherie, L., Kumar, S., Ledebur, K., Lohse, A., & Sliwa, K. (2026). Cultural evolution of beauty standards. Proceedings of the National Academy of Sciences, 123(21). https://doi.org/10.1073/pnas.2602380123

Brederecke, J., et al. (2020). Development and validation of the Self-Image Scale: Measuring body image in romantic relationships. PLOS ONE, 15(3), e0230331. https://doi.org/10.1371/journal.pone.0230331

Calogero, R. M., et al. (2009). Complimentary weightism: The potential costs of appearance-related compliments. Psychology of Women Quarterly, 33(2), 201-209. https://doi.org/10.1111/j.1471-6402.2008.01479.x

Creed, W. E. D., et al. (2014). The shame nexus: How shame and its institutional reproduction shape organizational life. Academy of Management Review, 39(2), 157-185. https://doi.org/10.5465/amr.2012.0074

Glamour. (2012, July 24). 5 things you never knew about Photoshop and fashion images. https://www.glamour.com/story/5-things-you-never-knew-about

Halley, J. (2006). Divided a nation: The case against same-sex marriage. In L. B. Nielsen (Ed.), The role of law in politics.

Harjunen, H. (2019). Fat bodies in public exercise spaces. Fat Studies, 8(1), 34-49. https://doi.org/10.1080/21604851.2019.1561101

Jefferson, B. J. (2019). Digitize and punish: Racial criminalization in the digital age. University of Minnesota Press.

Nagy, V., Poole, L., Banting, E., & Satherley, R. (2025). An interpretative phenomenological analysis of lived experiences and psychological processes in internalized weight stigma. British Journal of Health Psychology, 30(2). https://doi.org/10.1111/bjhp.12804

Park, S. (2017). Comparison of body composition between fashion models and women in general. Physical Activity and Nutrition, 21(4), 22-28. https://doi.org/10.20463/jenb.2017.0032

Thomas, E. M., et al. (2021). Impression management in hostile environments: How athletes in weight-stigmatized sports navigate body image threats. Women in Sport and Physical Activity Journal, 29, 71-81. https://doi.org/10.1123/wspaj.2020-0049

I was told about a doctor who told a fat woman with stage 4 kidney disease that she would not get a transplant from him because she was fat. His words were, “You will not get a transplant from me. Do you think I will cut through all that fat to get to your kidney?” The line is so ugly it almost feels unreal, except it is real, and that is exactly why it fuels me. She had waited ages for that appointment, had flown all the way to another state. She went in hoping for a kidney… a kidney she needed to live… and came home with the kind of humiliation that lasts a lifetime. A lifetime which, in her case, was being cut short because she was fat.

BMI has never been a clean measure of anything that matters here. If BMI determined the people who didn’t get kidneys, or other organs they needed, then a BMI cutoff of 35 excludes roughly 53 million U.S. adults, and a cutoff of 40 still leaves out about 25 million, using the 2024 adult population estimate and NHANES prevalence data (Emmerich et al., 2024; U.S. Census Bureau, 2024).

So when a transplant doctor hides behind a BMI threshold, it is not drawing a neat line between safe and unsafe bodies. It is deciding that a very large number of people can literally be left to die.

Weight discrimination has been associated with a nearly 60% increased risk of mortality, even after accounting for BMI, physical activity, and underlying disease burden (Sutin et al., 2015). The stigma itself is doing work. It gets under the skin and it changes behavior. It changes whether people return to care, whether they trust the next doctor, whether they keep trying when a system keeps telling them they are too much and somehow still not enough (Lavelle et al., 2022).

There is probably a non-zero number of you reading this and thinking, quietly to yourself, that the doctor from this story isn’t just espousing fatphobia flippantly, right? That there is clearly some data to justify excluding fat people from surgeries, or organs, or, you know, living.

The data actually says the opposite.

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The claim that fat people cannot survive surgery, or that a higher BMI makes a transplant too risky, does not hold up. A 2015 UK Renal Registry study tracked over 17,000 kidney transplant recipients and found that every single BMI group,including the highest, had significantly better survival than patients who stayed on dialysis. There was no significant difference in patient or graft survival between the BMI groups (Krishnan et al., 2015). A meta-analysis of over 200,000 kidney transplant recipients found that higher BMI was not a barrier to survival or success. In fact, patient survival actually favored heavier recipients (Lafranca et al., 2015). A review of over 83,000 transplant patients found that fat recipients survived at the same rates as thin recipients (Hill et al., 2015). And a 2023 study confirmed that survival was not significantly different across BMI classes in kidney transplant recipients (Bellini et al., 2023).

My friend Liz mentioned to me that she’d heard that they use BMI because surgery and anesthesia is “more dangerous” for people who are fatter. The data still doesn’t support those societal assumptions. A 2023 meta-analysis of nearly 1.9 million surgical patients found that patients with obesity (including class I, II, and III) had lower 30-day mortality rates than patients with normal BMI after general surgery (OR 0.75, p < 0.0001). Even in emergency surgery, obesity was associated with lower mortality. And there was no significant difference in complication rates between class I/II obesity and normal BMI patients (Cullinane et al., 2023).

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Fat people survive transplants. Fat people survive surgery. The bodies that doctors claim are too risky are the same bodies that the evidence says will do just fine (MacLaughlin et al., 2019). What we are looking at is a system that has decided, without evidence, that certain bodies do not deserve care. And the consequences of that decision are not abstract. They are people going home without kidneys. They are people dying on dialysis because a BMI number in a chart told a doctor that they were not worth saving.

This is what fatphobia looks like when it is baked into policy. It does not have to announce itself as discrimination or hatred. It can hide behind a threshold, behind a “standard of care,” behind a sentence like “we just want to make sure you are safe.” But the data says otherwise.

The AMA itself has acknowledged that BMI is not a reliable measure of health on its own (AMA, 2023). The metric that underpins these exclusionary policies was never designed to measure individual health in the first place (Heymsfield et al., 2024). It was built by a mathematician in the 1830s to describe the “average man,” who, for him, was white male Europeans, and white male Europeans alone, not to predict across populations in general who would survive a transplant.

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Being fat does not ruin your organs. It does not mean your kidneys are shutting down or your liver is failing. Most fat people are walking around every day with perfectly functional organs, going to work, raising kids, living their lives. Studies have repeatedly found that many people with higher BMIs have healthy blood pressure, cholesterol, insulin sensitivity, and liver function (Scientific American, 2024).

So here is the part people like to shrug off. Fatphobia gets treated like a lesser form of discrimination, as if it is just vanity talk, a joke about willpower, or a sensitivity issue instead of something that changes who gets believed, who gets treated, and who gets left out of care. That shrug is part of the harm. If you keep calling it not a real problem, then you never have to face the fact that it is sitting inside the system, shaping decisions, and making some people sicker while everyone else gets to pretend it is harmless.

So here is the question I keep circling back to: if the evidence says fat people survive, if the evidence says BMI is not a reliable measure of individual health, if the evidence says weight stigma itself kills, then why are we still letting a completely arbitrary number on a chart decide who lives and who dies?

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Neutral sounding rules do not become fair just because they are rules. If I told you that organ allocation policy, something that is supposed to be objective and science-based, also discriminates against Black candidates, you might be outraged. But this is, in fact, true, and it has been documented across repeated policy efforts (Kim et al., 2022). Racial inequities have persisted despite policy changes, showing that the system itself can hide bias while looking like a neutral process. By relying on BMI as a gatekeeper for organs, medicine does the same thing. It sounds objective while still deciding that some people are socially acceptable to deny, delay, and discard.

We have let a bigoted, arbitrary metric do the emotional work for us. It gives prejudice a number, gives our disgust a doctrine, give our desire for superiority a medical cosplay. Once that happens, people do not have to defend fat exclusion as hatred, they can just call it “logic.”

References

American Medical Association. (2023). AMA adopts new policy clarifying role of BMI as a measure in medicine [Press release]. https://www.ama-assn.org/press-center/ama-press-releases/ama-adopts-new-policy-clarifying-role-bmi-measure-medicine

Bellini, M. I., Deurloo, E., Consorti, F., & Herbert, P. (2023). Body mass index affects kidney transplant outcomes: A cohort study over 5 years using a steroid sparing protocol. Frontiers in Endocrinology, 14, 1106087.

Cullinane, C., Fullard, A., Croghan, S., Elliott, J. A., & Fleming, C. (2023). Effect of obesity on perioperative outcomes following gastrointestinal surgery: Meta-analysis. BJS Open, 7(4), zrad026.

Emmerich, S. D., Fryar, C. D., Stierman, B., & Ogden, C. L. (2024). Obesity and severe obesity prevalence in adults: United States, August 2021-August 2023. NCHS Data Brief, 508.

Heymsfield, S. B., Sorkin, J. D., Thomas, D. M., Yang, S., Heo, M., McCarthy, C., Brown, J., & Pietrobelli, A. (2024). Weight/height : Mathematical overview of the world’s most widely used adiposity index. Obesity Reviews, 25(S1), e13842.

Hill, C. J., Courtney, A. E., Cardwell, C. R., Maxwell, A. P., Lucarelli, G., Veroux, M., Furriel, F., Cannon, R. M., Hoogeveen, E. K., Doshi, M. D., & McCaughan, J. A. (2015). Recipient obesity and outcomes after kidney transplantation: A systematic review and meta-analysis. Nephrology Dialysis Transplantation, 30(8), 1403-1408.

Kim, I., Martins, P. N., Pavlakis, M., Eneanya, N. D., & Patzer, R. E. (2022). Past and present policy efforts in achieving racial equity in kidney transplantation. Current Transplantation Reports, 9(2), 114-118. https://doi.org/10.1007/s40472-022-00369-y

Krishnan, N., Higgins, R., Short, A. H., Zehnder, D., Pitcher, D., Hudson, A., & Raymond, N. T. (2015). Kidney transplantation significantly improves patient and graft survival irrespective of BMI: A cohort study. American Journal of Transplantation, 15(8), 2095-2102.

Lafranca, J. A., IJermans, J. N., Betjes, M. G., & Dor, F. J. (2015). Body mass index and outcome in renal transplant recipients: A systematic review and meta-analysis. BMC Medicine, 13, 174.

Lavelle, K., Zukauskaite, A., Jamieson, S., & Reilly, J. (2022). A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network. Obesity Science and Practice, 8(3), 325-335.

MacLaughlin, H. L., & Campbell, K. L. (2019). Obesity as a barrier to kidney transplantation: Time to eliminate the body weight bias? Seminars in Dialysis, 32(4), 325-331.

Scientific American. (2024, June 25). People who are fat and healthy may hold keys to understanding obesity. https://www.scientificamerican.com/article/people-who-are-fat-and-healthy-may-hold-keys-to-understanding-obesity/

Sutin, A. R., Stéphan, Y., & Terracciano, A. (2015). Weight discrimination and risk of mortality. Psychological Science, 26(11), 1663-1669.

U.S. Census Bureau. (2024, December 19). Net international migration drives highest U.S. population growth in decades [Press release].

And what age are you now?

I ask because the number of people who started dieting in their teens or twenties and are still dieting in their forties, fifties, and sixties is …almost everyone who diets (Garfinkel & Dorian, 1996). Yet people continue to seek out new diets, try old diets again, and just keep at it, fully believing that if they find the diet that works for them, they’ll achieve success.

The natural assumption within society is that there is a diet out there that will make someone thin. But I want to propose a different truth: that dieting at all is altering the body just enough to necessitate a lifetime of dieting and, overall, making us fatter.

Sure, you may think I’m a big (fat) liar, but unfortunately, the data is with me. Restrictive eating for weight control is a robust predictor of weight gain (Bacon & Aphramor, 2011; Mann et al., 2007). Dieters often end up heavier than when they began. The body does not just return to its starting weight. It overshoots.

Calorie restriction changes the body in ways that make regain more likely. When you restrict calories, your resting metabolic rate drops. Researchers tracked 14 of the contestants from The Biggest Loser for six years after the show. They found that the contestants’ resting metabolic rates had stayed depressed, burning roughly 500 calories fewer per day than expected for people of their size (Fothergill et al., 2016). That meant they had to eat dramatically less than someone their size just to maintain their current weights, and normal eating would push the weight back on.

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Leptin, the hormone that tells the brain the body has enough energy stored, plummeted during The Biggest Loser competition and stayed suppressed years later (Fothergill et al., 2016). That drop in leptin is the brain’s way of hearing the body is running on fumes, so it ramps up hunger and dials back energy use to force recovery.

These revelations aren’t new, either! Or even prompted by Jillian Michaels shouting at the scientists, which is obviously the most effective method for success . The 1940s Minnesota Starvation Experiment showed that healthy men on semi-starvation diets became obsessed with food, talked about eating constantly, and in some cases developed severe psychological distress (Keys et al., 1950). Those reactions were produced by restriction itself. Once food comes back, bingeing and preoccupation do too, which is why restrictive eating can create the very behaviors it claims to prevent. Deprivation rewires attention and appetite, which is the real problem, not a lack of strength or willpower.

It may feel easy to believe that, while the data might say that the body responds to dieting by wanting to get fat, that doesn’t apply to you, or your diets, the research actually says that you might be the big (fat) liar. A Finnish twin study tracked more than 4,000 twins from adolescence to age 25 and found that women who dieted even once were 2.7 times more likely to become overweight than their non-dieting peers, and those who dieted twice or more were 5.2 times more likely (Pietiläinen et al., 2012). More diets meant more fat.

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When researchers compared identical twins where one had dieted and one had not, the dieting twin was still measurably heavier at 25, even though they shared the same genes and upbringing. A large Australian cohort study found the same dose-response relationship: people who had never dieted were the baseline, those who dieted once had 1.9 times the odds of obesity, those who dieted more than once had 2.9 times the odds, and chronic dieters had 3.2 times the odds (Siahpush et al., 2015). I’m pretty sure this is the part in the Bible, where diets beget diets beget diets, and they all beget fatness.

At this point, you might be questioning everything you thought you knew. It’s like I’m telling you that Santa isn’t real. Because one of the most widespread beliefs that is the beating heart of dieting is that caloric restriction is “basic math” and is “always” going to be successful for weight loss, if you can “stick with it.”

Calories-in, calories-out sounds tidy on paper, but bodies are not passive calculators. The National Institutes of Health said as much decades ago when it concluded that dieting is an ineffective way to produce sustained weight loss (NIH, 1992). A large review later found that only about 5% of people sustained their target loss long term (Mann et al., 2007).

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So if we have known since the 1940s that restricting food makes people obsessed with food and gain weight, why does everyone still believe that diets work? Because the diet industry runs on failure. In the United States alone, the diet industry brought in 72 billion dollars in 2018 (Global Wellness Institute, 2019). The 95% failure rate is the business model. When the product does not work, consumers are told the problem is their discipline. Diet culture managed to invent a problem and then invent a solution that does not work, and we keep paying for it because we have been convinced the fault is ours (Fishman & Freespirit, 1978; Lyons, 2009).

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And the cycling itself can do damage. One study found that women who lost and regained weight showed a worse cardiometabolic risk profile at follow-up, even if they weighed less than they had at baseline (Gaesser, 2003). So the person who keeps dieting is often left in the worst possible place, harming their bodies, hungrier than before, and more convinced that the next round has to be stricter.

People who diet usually love treadmills, and this pattern sure is one. Your body is responding exactly as bodies evolved to respond when they think that food is scarce.

There is probably not a single person reading this post who has not been on a diet, or who is not on one even right now. And the worst part is, once dieting becomes the language you use to talk to yourself, it can start to sound like truth.

But what you can do is put down the fantasy that the next round will finally fix you, and begin choosing steadiness over punishment, nourishment over panic, and a life that does not revolve around the scale.

References

Bacon, L., & Aphramor, L. (2011). Weight science: Evaluating the evidence for a paradigm shift. Nutrition Journal, 10(9).

Fothergill, E., Guo, J., Howard, L., Kerns, J. C., Knuth, N. D., Morber, R., ... & Hall, K. D. (2016). Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity, 24(8), 1612-1619.

Garfinkel, P. E., & Dorian, A. (1996). The psychology of dieting. In R. B. Fairburn & K. D. Brownell (Eds.), The psychology and treatment of eating disorders. Guilford Press.

Gaesser, G. A. (2003). Thinness and weight loss: Beneficial or detrimental to long-term health? Obesity Research, 11(9), 1029-1036.

Global Wellness Institute. (2019). Worldwide research initiative: Global wellness economy monitor.

https://globalwellnessinstitute.org/

Keys, A., Brozek, J., Henschel, A., Mickelsen, O., & Taylor, H. L. (1950). The biology of human starvation (2 vols.). University of Minnesota Press.

Lyons, P. (2009). Dieting and the making of fat human subjects. Body & Society, 15(4), 53-73.

Mann, T., Tomiyama, A. J., Westling, E., Lew, A. M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220-233.

Pietiläinen, K. H., Saarni, S. E., Kaprio, J., & Rissanen, A. (2012). Does dieting make you fat? A twin study. International Journal of Obesity, 36(3), 456-464.

Siahpush, M., Tibbits, M., Shaikh, R. A., Singh, G. K., Sikora Kessler, A., & Huang, T. T.-K. (2015). Dieting increases the likelihood of subsequent obesity and BMI gain: Results from a prospective study of an Australian national sample. International Journal of Behavioral Medicine.

National Institutes of Health. (1992). Methods for voluntary weight loss and control: NIH Technology Assessment Conference Panel. Annals of Internal Medicine, 116(10), 930-946.

Sumithran, P., Prendergast, L. A., Delbridge, E., Purcell, K., Shulkes, A., Kriketos, A., & Proietto, J. (2011). Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine, 365(17), 1597-1604.

But the idea of “proportionizing “ as coined by drag queen Eureka O’Hara, or dressing with your resulting proportions in mind, has been the centerpiece of my inner fashion monologue ever since I started caring about clothing in my 20s. For me, as someone with big arms, a big ass, a small waist, and a short torso, it means always choose fit and flare silhouettes on the bottom, shirts with sleeves, and everything nipped in at the waist. I’m like a human land mermaid.

My trust in the concept of dressing “flatteringly” is starting to change though.

Because what is “flattering” actually short for? That it makes you look more aesthetically pleasing? Pleasing to whom? That it hides the things you are not supposed to have? A stomach? An ass? What we are really saying when we call something flattering is that it makes your body less visible, less objectionable, less of the thing it actually is.

As a fat person, no dress is going to make me look NOT fat. Clothes aren’t going to make me a different size. And I don’t want my wardrobe to be a lifelong project dedicated to creating the optical illusion that I take up less space. That is what “flattering” actually asks you to sign up for. Not a compliment. A commitment to looking like someone else. It arrives in a changing room from a friend who means well, probably from your mother, from a sales associate who seems to be on your side. It never sounds like a rule. It sounds like kindness. But the unspoken deal is that your body is wrong as it is, and your job is to use clothing as one of the tools in your arsenal to fix the problem. And though it hides this, accentuates that, cinches here and drapes there, what it’s supposed to hide or showcase doesn’t seem to be a fixed aesthetic. We’re not really sure whose standard we’re following.

Research backs this up. A qualitative study found that clothing practices are an active part of how people manage body distress. Women reported using clothing strategically to hide “problem areas,” accentuate “assets,” and “flatter the figure.” These behaviors fluctuated depending on whether it was a “fat day” or a “thin day,” revealing that body evaluation and clothing choices are locked in a feedback loop (Grogan et al., 2013). The word “flattering” isn’t just describing a garment. It is activating a self-regulatory system where the body is constantly being assessed and corrected.

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Who are we trying to look like, though?

The “flattering” standard maps almost perfectly onto a body that is young, thin, white, and able-bodied (Stice et al., 2001; Lewis, 2019; Becker et al., 2013; Foster & Pettinicchio, 2021). Fashion’s idea of what “works” was designed by and for that body, and then sold to everyone else as universal truth. When you’re told something isn’t flattering, what you are really being told is that you have deviated from the default. Not that the garment failed, but that you did. “Flattering” is a word that works overtime on fat bodies and aging bodies. Don’t show your arms. Don’t wear a bikini if you’re fat. Flashy clothes are only for the young. Cover your wrinkled legs. Hide your saggy tits. Smooth over the rolls.

Women have been assigned shapes that carry their own rankings. Apple-shaped, pear-shaped, hourglass, inverted triangle. Every one of these categories comes with an implicit verdict, and a corresponding codex of what flatters each one. Sometimes you want the pear. You never want the apple. Become a California Raisin. Spend your life trying to become a different fruit. Your brain becomes jelly.

Men don’t have shapes. Nobody is looking at a man and saying, “unfortunately he is rhombus-shaped.” Men just get to have bodies. We’re over here, fruits and shapes and trying to figure out which one is you, which one is right, and how you’re supposed to dress yourself to be the best fruitshape before you become fruit leather. You learn to see yourself from the outside before you ever feel yourself from the inside.

The subtext is always the same: some bodies are acceptable to look at, and some bodies need to be managed before they’re presented to the world. The rules about what is “flattering” are really rules about who is allowed to take up visible space without apology, and the rest of us are expected to do the work of disappearing on our own time.

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“Flattering” occupies a weird space, linguistically. It never sounds like a command. It sounds like someone is looking out for you. “I’m just being honest.” “I just want you to look your best.” But the underlying message is always that you should not be seen too much. Do not let your body be the thing people notice. Use clothing to manage other people’s perceptions. Or in my case, never show off your tree trunk legs. Making it seem honest and earnest is how the surveillance stays invisible.

A 2026 paper by Zhu describes how this works: the watching doesn’t come from one authority. It comes from everywhere at once: your mother, your friends, social media, the woman next to you on the bus. Women learn to watch and correct their own bodies because everyone around them is doing the same watching. “Flattering” is one of the ways that watching gets passed around. It does not come from a uniformed authority, but instead comes from a friend in a changing room, which makes it harder to resist (Zhu, 2026).

You don’t even NEED a friend in the changing room now, since the clothes are all labeled to let you know just exactly how they’re going to fix you. “Tummy control.” “Body sculpting.” “Smoothing.” Every product label is another version of the same message: your body, unmodified, is not enough. The garment is not just shaping your body. It is shaping your idea of what your body is supposed to be.

Body image researchers are worried. Victoria Kleinsman, a self-esteem coach who works with women aged 13 to 60, described shapewear as an “IRL filter” for the body. She works with women who are crying on Zoom calls about what their bodies look like, wearing spandex shapewear and tights in boiling weather because they are afraid of what others will think about them due to their body size (Karmali, 2023).

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And then there is the word itself. Shapewear. Your body already has a shape, and it’s probably a fruit. But the name tells you that what you have is not a GOOD shape yet. It is just a body, waiting to be shaped into something acceptable. The product doesn’t even try to hide what it thinks of you … it puts it in the name!

Objectification theory describes what happens next: women internalize the outside gaze and begin watching their own bodies the way someone else would, constantly monitoring how they look, treating their appearance as something to manage and optimize. Researchers call this self-objectification. It’s not vanity; it’s what happens when a culture treats your body as an object to be evaluated, and you absorb that evaluation as your own. Women who self-objectify invest more time and money in appearance maintenance and report fewer positive feelings toward their own bodies (Fredrickson & Roberts, 1997).

So when we talk about the word “flattering,” it’s not just about language. It’s about products. “Flattering” tells you your body is a problem. Shapewear sells you the solution. But the solution is temporary, and the insecurity it creates is not. You wear the shapewear, you get the compliment, the compliment reinforces the idea that the shapewear was necessary, and the cycle repeats. The garment comes off and you are back where you started, except now you’re hyper aware of how “wrong” you look without it. That knowledge does not go away.

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But it doesn’t have to persist.

“Flattering” is externally focused by design. You are no longer dressing for yourself. You are dressing for someone else’s approval, someone else’s gaze, someone else’s idea of what your body is allowed to look like. But what actually draws people in has nothing to do with the garment’s corrective ability. People respond to confidence. They respond to ease, to humor, to the energy of someone who is comfortable taking up space. What’s flattering, it turns out, is a good mood and the absence of apology. The garment is not doing the work. The person wearing it is.

When I was pregnant, the stretchy lycra dresses that clung to my belly felt glorious. For years, those same dresses had hung loosely on me because I was terrified of fabric clinging to my midsection. But when I was pregnant with twins, everything clung to my midsection and I couldn’t do anything about it. The dress hadn’t changed. What changed was that I no longer felt like I needed to be ashamed. Pregnancy made my belly socially acceptable, and suddenly the same garment that would have felt like exposure felt like freedom, because no one could accuse me of it being unflattering.

That shift does not require a new wardrobe. It requires noticing, every time the word “flattering” shows up, what it is actually asking you to do. And then deciding whether that is a project you still want to participate in. Because the real question is not whether an outfit is flattering. The real question is: flattering to whom?

References

Becker, C. B., Diedrichs, P. C., Jankowski, G., & Werchan, C. A. (2013). I’m not just fat, I’m old: Has the study of body image overlooked “old talk”? Journal of Eating Disorders, 1(1), 6. https://doi.org/10.1186/2050-2974-1-6

Foster, J., & Pettinicchio, D. (2021). A model who looks like me: Communicating and consuming representations of disability. Journal of Consumer Culture. https://doi.org/10.1177/14695405211022074

Grogan, S., Gill, S., Brownbridge, K., Kilgariff, S., & Whalley, A. (2013). Dress fit and body image: A thematic analysis of women’s accounts during and after trying on dresses. Body Image, 10(4), 525-532.

Karmali, S. (2023, June 12). Shapewear is booming, and body image experts are worried: ‘It’s really dangerous.’ The Independent. https://www.independent.co.uk/life-style/fashion/shapewear-skims-control-pants-bodysuits-b2354685.html

Lewis, R. (2019). Modest body politics: The commercial and ideological intersect of fat, Black, and Muslim in the modest fashion market and media. Fashion Theory. https://doi.org/10.1080/1362704x.2019.1567063

Liu, Z. (2023). Research on the Use of Social Media to Grasp Consumers’ Psychology and Create Traffic: A Case Study of Brandy Melville. SHS Web of Conferences, 155, 02017. https://doi.org/10.1051/shsconf/202315502017

Patowary, U. (2024). Body Image and the Role of Women’s Innerwear in Shaping Perceptions. Research Journal of English Language and Literature, 12(4), 70–87.

Fredrickson, B. L., & Roberts, T. A. (1997). Objectification theory: Toward understanding women’s lived experiences and mental health risks. Psychology of Women Quarterly, 21(2), 173-206.

Shetty, K. J., & Kotian, S. (2023). A Systematic Review and Research Agenda of Body Image and Fashion Trends. International Journal of Case Studies in Business IT and Education. https://doi.org/10.47992/ijcsbe.2581.6942.0281

Stice, E., Spangler, D. L., & Agras, W. S. (2001). Exposure to media-portrayed thin-ideal images adversely affects vulnerable girls: A longitudinal experiment. Journal of Social and Clinical Psychology, 20(3), 270–288. https://doi.org/10.1521/jscp.20.3.270.22309

Zhu, X. (2026). The Double Erosion: Beauty Anxiety and Consumerism as Dual Mechanisms Undermining Women’s Bodily Autonomy. Lecture Notes in Education Psychology and Public Media. https://doi.org/10.54254/2753-7048/2025.nd34310

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I have spent a lot of pixels on this Substack making claims that should feel uncomfortable. That the data for the obesity epidemic itself is nowhere near as solid as we have been told.

That the decision to deprive fat people of ventilators during COVID-19 was made on the basis of assumptions , not evidence.

But there is probably not a small percentage of you who believe, fully, that being fat is unhealthy. That it is proven by science.

So I want to introduce you to the Obesity Paradox.

Across dozens of studies spanning heart failure, coronary artery disease, kidney disease, stroke, diabetes, sepsis, cancer, COPD, and multiple surgical populations, people classified as overweight or obese consistently show better survival outcomes than thinner patients with the same diagnoses.

Not always or in every condition. But often enough, and across enough contexts, that the pattern should be hard to ignore.

Instead, they call it “the obesity paradox” and continue assuming the worst of fat people everywhere.

The obesity “paradox” shows up in a lot of places. A review of 58 studies found that the pattern holds strongest in older adults dealing with serious illness (Dramé and Godaert, 2023). In patients fighting sepsis and cancer, higher BMI was linked to better survival at every time point measured (Hou, Qi, Zhang, et al., 2025). And in heart failure patients over 85, the same pattern showed up again (Tachibana, Kubota, Nishino, et al., 2026). The same pattern has been documented in dialysis patients (Doshi et al., 2015), chronic obstructive pulmonary disease (Cao et al., 2012), and the critically ill (Pepper et al., 2016). And the more advanced the disease, the more pronounced the survival advantage of carrying extra weight becomes.

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And for those who say “oh, it’s just fat people having extra reserves to survive long hospital stays.” No. After an acute heart attack, fat patients consistently survive at higher rates than thinner ones. A meta-analysis of STEMI patients found that overweight and obese patients had significantly lower mortality than normal-weight patients, an effect that persisted across in-hospital, short-term, and long-term follow-up (Liu et al., 2023). A nationwide study of over 125,000 AMI hospitalizations confirmed a J-shaped relationship, where BMI above 25 was an independent predictor of lower mortality. An acute heart attack is not a prolonged illness where extra energy stores would matter. It is a sudden cardiac event. The survival advantage is something the framework cannot explain.

The obesity paradox is not a fluke.

It’s a pattern so consistent that the insistence on calling it a paradox tells us more about the people doing the labeling than about the bodies being studied.

Because calling it a paradox does a lot of quiet work.

A paradox is something strange but ultimately dismissible. An exception that proves the rule.

The term allows medicine to preserve its original assumption, that fatness itself is the causal agent of poor outcomes, while treating contradictory evidence as an anomaly rather than a challenge to held beliefs.

Fat is bad. The patient is the problem. Our assumptions do not need revisiting.

But is that really true in the case of obesity?

If there are all of these studies saying that being fat lead to better outcomes, are those outliers, because we just “know” that being fat is unhealthy, right?

Our assumptions are what we might call emotional truth.

Science is supposed to be the process of setting aside what we feel should be true in favor of what we can actually prove is true.

But when it comes to fat bodies, that process has been reversed.

The emotional belief that fat is a failure, a risk, a thing to be feared, is treated as the primary fact.

We have allowed a collective emotional response to encroach upon the territory of factual science.

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That is not science. That is a story we are all agreeing to pretend is true.

And this is where it stops being abstract for me. The data keeps showing something different from what we have been told. That means the problem is not just the paradox. It is the framework we built around it.

And that framework starts with BMI.

The BMI was created in the 1830s by a Belgian mathematician named Adolphe Quetelet (Eknoyan, 2008). He was not studying health or fatness. He was studying population averages, trying to describe the average man using statistics (Grue & Heiberg, 2006).

He based his formula on white European men (Strings, 2019) and explicitly said it should not be used to judge individuals. He did not even include women or people of color, who, as the American Medical Association recently noted, are still being victimized by a metric based on an “imagined 19th-century Caucasian ideal” (AMA, 2023).

When physiologist Ancel Keys repopularized the formula in 1972, he himself warned that it would be “scientifically indefensible” to use BMI to classify individuals for clinical purposes (Keys et al., 1972).

Now it determines your insurance rates, your access to surgeries, and whether your doctor takes your symptoms seriously.

Here is the problem with BMI as a category. It groups together people with radically different bodies under a single label.

BMI scales weight to height without distinguishing between adipose tissue and muscle tissue. Two people with identical BMIs can have radically different metabolic profiles (Cespedes Feliciano et al., 2018; Bray, 2023).

Dwayne “The Rock” Johnson lands in the same BMI category as millions of other people with his height and weight. That category tells you nothing about his muscle mass, his body fat percentage, or his metabolic health.

It tells you nothing about any of them.

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And yet patients are grouped by BMI. Outcomes are analyzed by BMI group. Differences are attributed to BMI. BMI is then cited as proof that BMI is causal.

It’s a circular logic frame that should be questioned a lot more than it is. I’ll try to anchor it in the real world.

You call a neighborhood “high crime” and so you send more policemen there. As a result, more arrests happen. The natural consequence of more policemen is more surveillance and encounters.

The data from the increased arrests is cited as proof that the neighborhood is dangerous. More policemen are deployed, and more arrests happen. The cycle is confirming itself.

When researchers disaggregate BMI sorting, outcomes begin to make sense.

Survival varies with fitness, metabolic health, inflammatory burden, disease stage, recent weight loss, treatment intensity, and access to care.

People in higher BMI categories who survive longer are not surviving for some magical fat-related reason.

They are surviving because they differ in ways BMI cannot see and does not account for.

When you dump millions of radically different people into the same bucket and analyze the bucket as though it were a single body, the results are going to be naturally messy.

But the mess is not in the bodies. It is in the bucket.

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We have reached a point where the names of the categories don’t even match the data they’re supposed to describe. The largest meta-analysis ever conducted on the subject, covering 2.88 million people, found that the “overweight” category has a significantly lower mortality risk overall than the “normal” weight category (Flegal et al., 2013).

The weight we have labeled as a medical warning sign is statistically the safest place to be for longevity.

The obesity paradox is not a paradox at all. It is what happens when you use a crude population-level statistic as though it were a medical diagnosis.

There is an association between higher BMI and certain health risks at the population level (Di Angelantonio et al., 2016; GBD 2015 Obesity Collaborators, 2017). That association is real.

But association is not causation.

And the strongest test we have for distinguishing correlation from causation backs this up. Mendelian randomization studies use genetic variants to determine whether a relationship is truly causal, bypassing the confounders that plague observational research. When researchers applied this method to adiposity and mortality, they found no causal effect of excess body fat on all-cause mortality (Kim et al., 2021). The framework that treats fatness as a universal death sentence is built on observational correlations that do not survive the strongest causal test science has.

Population-level patterns do not automatically apply to individual bodies. Confounders such as socioeconomic status, weight cycling, and medical bias are baked into these associations.

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And medical bias is a massive part of that equation.

Medical students don’t just learn anatomy in a vacuum. They’re taught by people. If society is any indication, a large percentage of those people are fatphobic.

A national study of 4,732 first-year medical students found that 74% exhibited implicit weight bias and 67% exhibited explicit weight bias (Phelan et al., 2014).

Over the four years of medical school, those negative attitudes worsened, not improved (Phelan, Puhl, et al., 2015). Students watch their teachers use stigmatizing language in patient records, phrases like “limited by body habitus.” They internalize the way senior doctors dismiss fat patients as non-compliant or unmotivated (Goddu et al., 2018).

When the people teaching you are steeped in a collective emotional truth that fatness is a moral and medical failure, that bias does not just disappear when you look at data.

It shapes how you design the study, how you group the participants, and which conclusions you are willing to see.

I know this is uncomfortable.

If you are someone like me who trusts science, who believes in evidence-based medicine, this feels like dangerous territory.

It feels like the kind of argument that ends with someone selling you supplements or a vagina candle. All while sitting in a hot tub with jeans on. But this is not a conspiracy theory. This is not vibes. This is the data that medicine itself produced.

The conclusion is not that science is wrong. The conclusion is that science has been abandoned in this specific area, and emotional beliefs have been allowed to override what the evidence actually shows.

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This isn’t the first time this has happened and it probably won’t be the last, but pretending it doesn’t happen ever is naive.

Take the history of hysterectomies in the United States. For decades, the medical establishment decided that the uterus was a “useless and pathological” organ once a woman was done having children. In 1993, a congressional hearing revealed that between 24 and 30 percent of all hysterectomies performed in the U.S. were medically unnecessary (U.S. Congress, 1993). The procedures were framed as “preventative,” but they were driven by an emotional truth held within patriarchy that was being propagated by bad science (Becker, 2023; Moore et al., 2023).

We did eventually stop giving women random hysterectomies, not because their biology changed, but because we finally acknowledged the bias that was driving the surgery.

So what happens when that bias gets embedded in care itself?

Fatigue, pain, and shortness of breath are no longer warning signs of potentially larger problems. They are treated as the inevitable tax of a high BMI. The diagnostic lens narrows until everything is funneled through a single explanatory frame, fatness, before any alternative causes are even considered (Puhl & Heuer, 2010).

This is a well-documented phenomenon known as diagnostic overshadowing (Jones et al., 2008). Body size becomes the salient characteristic that eclipses any other plausible diagnoses.

And it is not happening because individual doctors are cruel.

We have set up this framework to support the idea that fatness is dangerous and unhealthy. The framework we established is doing our work for us.

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It does this in at least three ways.

First, fat people stop going to the doctor. Study after study shows that healthcare professionals hold some of the strongest anti-fat attitudes of any group (Tomiyama et al., 2018; Puhl et al., 2021).

A 2023 study of 3,267 US resident physicians found explicit weight bias across every specialty. Orthopedic surgery and anesthesiology scored highest. Primary care scored only slightly lower (Philip et al., 2023). A multinational study of nearly 14,000 adults found that among participants who reported a history of weight stigma, two-thirds said it came from their doctors (Puhl et al., 2021).

The result is that fat people disengage with the medical profession altogether. A 2025 study found that each additional weight-stigmatizing experience in a healthcare setting increased the odds of a patient avoiding care entirely by 31% (Robinson et al., 2025).

This is not fat people being irresponsible. This is fat people learning, after years of being dismissed or humiliated, that seeking medical help only makes things worse.

We understand this pattern in other contexts. When people in low-income neighborhoods stop calling the police, we recognize that as a rational response to a system that has failed them, not as moral failing. The same logic applies here.

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Then, when fat people do show up, doctors miss things. Weight gets treated as the explanation instead of the context, and the workup stops there.

Delays in cancer detection, missed cardiac symptoms, misattributed pain; these are not rare anecdotes. They are the predictable consequence of a system that treats body size as a diagnosis rather than as just another variable (Tomiyama et al., 2018).

And then the framework completes its own circle.

The very stigma fat people experience within the world, even in their own doctors’ offices, is making them sick. Weight stigma is a chronic stressor that disrupts cortisol regulation. It worsens the very metabolic and cardiovascular outcomes it claims to be warning against (Tomiyama, 2014; Steptoe & Frank, 2023).

The harm we attribute to fatness is, in part, harm we created by stigmatizing it.

As a scientist, and a fat woman, I feel let down in a way that is hard to describe.

Science is supposed to revise its conclusions when the evidence demands it. That is the whole point. And in this case, the evidence has been demanding it for decades.

We have known for years that the body is not a simple machine. The body is a biological system that actively defends its own size, and that size varies hugely.

Your brain is literally designed to monitor your hormones and ensure that your energy stores remain stable (Müller et al., 2018; Purnell & le Roux, 2024). Metabolic adaptation (Melby et al., 2017) is designed to keep you at a certain weight set point.

Yet our culture treats this natural, normal homeostatic regulation as some sort of moral failure.

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Seeing this evidence ignored by the very institutions I was taught to trust is crushing.

We have allowed a cultural obsession with thinness to corrupt the scientific process itself. We treat a biological survival mechanism as a character flaw.

Most of us view “Science” as a badge of tribal identity. We trust the experts. We trust the peer-review process. But what happens when scientists are blinded by their own biases; their own “emotional truths”?

When the people designing the studies, choosing the variables, and setting the conditions already believe fatness is the problem, the study does not challenge the assumption. It confirms it.

The bias is calling from inside the house.

This is not a vague concern. Researchers Cope and Allison coined the term “white hat bias” to describe exactly this: the distortion of information in the service of what researchers believe to be righteous ends (Cope & Allison, 2010). When scientists are convinced that obesity is the enemy, they unconsciously cherry-pick evidence, cite positive findings more often, and reinterpret studies that don’t support the conclusion. Their analysis found that this bias is strong enough to overwrite the data itself: when a study found no link between sugary drinks and weight gain, 84% of the subsequent papers that cited it misrepresented the results as showing a link. They were citing a study that proved nothing as if it were proof of their own assumptions.

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The scientific method has tools to guard against this: pre-registration of studies, double-blind designs, independent replication. The problem is not that science lacks the tools. The problem is that when the answer feels obvious or “true”, I guess we stop using them?

Consider the math we refuse to do out loud. Anorexia nervosa has the highest mortality rate of any psychiatric illness.

The research is unambiguous. People are dying from this failure to eat, one every hour, a rate that should alarm anyone paying attention (Arcelus et al., 2011).

And yet anorexia barely registers in the cultural conversation about dangerous bodies.

Obesity, on the other hand, is on every magazine cover.

It is the subject of panic headlines, public health crusades, and pharmaceutical campaigns worth billions.

It is the body type we have decided to pathologize with such intensity that people will accept any level of suffering if only it means becoming less fat and therefore more “healthy.”

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We have built a world where the condition that is actually killing people gets a fraction of the attention, and the condition we have decided to fear gets all of it.

The reason is not evidence. The reason is that we decided, culturally, that thinness equals health.

That equation is not backed up by science. It is a story we told ourselves so many times, we forgot it was fiction.

It feels dangerous to even ask these questions. You don’t want to sound like a conspiracy theorist. You don’t want to be associated with anti-institutional movements or health misinformation.

But science has abandoned us on this one.

The obesity paradox isn’t just a dumb phrase to describe the “phenomenon” that being fat isn’t the worst thing ever.

It’s the heavy lift of an entire industry to Jedi handwave away data that doesn’t fit into our pre-established emotional truth that being fat kills.

If medicine wants to remain worthy of trust, it owes us more than just naming the obesity paradox. It starts with identifying and acknowledging our own biases and how they are baked into a system that is literally killing fat people. And for gods sake, get rid of the fucking BMI. Not even the people who invented it or brought it back into vogue thought it should be used like this. Talk about bad science.

Science is supposed to be about questioning and learning from those questions. The paradox is not the problem. The refusal to learn from it is.

Fat bodies did not create this problem. They exposed it.

If you would like to subscribe and read the original series on the Obesity Paradox, it can be found here

References

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Boyland, E. J., Halford, J. C. G., Watson, E. K., & Harrold, J. A. (2014). Belief beyond the evidence: Using the proposed effect of breakfast on obesity to show 2 practices that distort scientific evidence. American Journal of Clinical Nutrition, 99(5), 957–965. https://doi.org/10.3945/ajcn.113.073528

Boyland, E. J., Halford, J. C. G., Watson, E. K., & Harrold, J. A. (2014). Belief beyond the evidence: Using the proposed effect of breakfast on obesity to show 2 practices that distort scientific evidence. American Journal of Clinical Nutrition, 99(5), 957–965. https://doi.org/10.3945/ajcn.113.073528

Cao, C., Wang, R., Wang, J., Bunjhoo, H., Xu, Y., & Xiong, W. (2012). Body mass index and mortality in chronic obstructive pulmonary disease: A meta-analysis. PLoS ONE, 7(8), e43892. https://doi.org/10.1371/journal.pone.0043892

Cope, M. B., & Allison, D. B. (2010). White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting. International Journal of Obesity, 34(1), 84–88. https://doi.org/10.1038/ijo.2009.239

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Cope, M. B., & Allison, D. B. (2010). White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting. International Journal of Obesity, 34(1), 84–88. https://doi.org/10.1038/ijo.2009.239

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It takes a predictable form. I’ll say “fat people can be healthy” and the response is “so you’re saying a 900-pound person on a ventilator is healthy?” You say “weight stigma is harmful” and the response is “so doctors should never talk about weight?” You say “bodies come in different sizes” and the response is “so we should just accept every body regardless of health consequences?”

The flag is always the same: a hypothetical body so extreme that almost no one would disagree that something is wrong. The move isn’t to argue with you. It’s to change the subject to a much easier position to defend, making you look like the unreasonable one for not endorsing it.

This is the fat straw man.

The fat straw man has a second layer that makes it feel… intuitive. It relies on an unspoken premise about how weight works, a folk theory that goes like this: fat is a runaway train. If you let yourself go even a little bit, there’s no natural stopping point. You will keep gaining until you hit the wall at 900 pounds, bedbound, on a ventilator.

What’s eating Gilbert Grape? It’s you, of course. Your hunger knows no bounds.

Baron Harkonnen , the bloated villain of Dune, is this cultural touchstone’s dad. He’s wed to Honey Boo Boo’s mom , the stage mom to all of our fat fantasies. They together serve as the pinnacle of greed and evil and sloth and grotesqueness, encapsulated in just a meme of Brendan Fraser’s sad bloated face in The Whale.

All televised on TLC for you to watch, of course.

The straw man draws on this iconography without even having to name it.

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When someone says “so you’re saying a 900-pound person on a ventilator is healthy?” they don’t need to explain what that image means. The culture already did the work. That body arrives preloaded with every accusation the straw man needs.

The unspoken worry is that body positivity is permission: permission to stop watching, permission to stop worrying, permission to let bodies do whatever they want. And if you give that permission, what’s the brake?

Body positivity at its most basic just asks you to stop assuming a fat body is a bad body. Stop assuming it’s unhealthy, or that it needs to be fixed, or that the person inside it has given up on something. That’s what thin bodies already get.

But the fat straw man reframes this as: “You want to tell people there are no consequences to any amount of weight gain. You want to give everyone permission to get as fat as they physically can.”

That reframing is the move. It takes a request for basic dignity and reinterprets it as a wholesale endorsement of unlimited weight gain. And the reason it lands is that people do believe, on some level, that fatness has no natural upper bound.

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The premise is not supported by the evidence. Body weight is regulated within a range by metabolic, hormonal, and neurological feedback loops. Set point models and dual intervention point models describe how the body actively defends against drastic deviation from a stable range (Speakman & Hall, 2023; Speakman et al., 2011).

Even intentional weight change, extreme dieting or overfeeding, is met with compensatory mechanisms like adaptive thermogenesis, which resists further deviation (Egan & Collins, 2021). Bodies settle. They do not plummet uncontrollably into a bed they will no longer be able to get out of.

A 22-year study followed women with anorexia and bulimia, the one group of people whose core fear is exactly the “runaway train” the straw man depends on. If letting go meant endless weight gain, this is where you would see it. Instead, their BMI increased most rapidly in the early years of recovery (from dangerously low weights) and then plateaued. After 22 years, 69% were normal weight and only 17% were overweight or obese (Burton Murray et al., 2017).

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About 40% of US adults have obesity (BMI ≥ 30). About 9% have Class III obesity (BMI ≥ 40). The “bedbound 900-pound person” the fat straw man invokes, with a BMI of 60, 80 or 100+, is a fraction of that 9%. A statistical rounding error (National Center for Health Statistics, 2023). There is no data on how many people fall into this category because they are not even statistically significant. It’s the public health equivalent of the boogeyman.

NHANES , the gold-standard CDC survey, stops its top bucket at BMI ≥ 40. The extreme case exists in our cultural imagination, fed by decades of TLC specials, freak-show framing, and moral panic, but not as a well-documented demographic reality. The straw man points at a statistical ghost to authorize blanket judgment of the other 30+ percent of adults who simply have bodies outside the acceptable range.

So what is the fear at the bottom of the fat straw man?

It isn’t that compassion for a fat person will somehow make that person thinner. It’s that compassion signals permission, and permission signals that the cultural guardrails against fatness are down. And if the guardrails are down, the reasoning goes, people will just keep gaining.

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This is the line the straw man never says aloud but absolutely depends on: the implication that fatness is just a lack of control, a lack of discipline. So if you remove the shame, the judgment, the constant cultural vigilance, what’s left?

If the only thing keeping people from getting as fat as humanly possible is their lack of acceptance by society, then body positivity genuinely is dangerous. The question behind every invocation of the bedbound hypothetical is: if we stop being afraid of becoming that, what stops anyone from getting there?

If you tell someone a dark pit is scary because there is a monster at the bottom, does that make it more frightening than if the pit is just darkness?

The fat straw man needs that monster. It needs the bedbound 900-pound body as a concrete, grotesque endpoint to make the fear feel justified. Without it, you are just asking people to sit with uncertainty. Bodies change. Weight fluctuates. That is uncomfortable, but it is not the same as a monster.

The fat straw man works because we have been trained to see fat as a dark pit with no bottom. But the bottom is not where most people are headed. It is where the culture has decided to fix its gaze so it can keep telling everyone else: you’d better be scared.

References

Burton Murray, H., Tabri, N., Thomas, J. J., Herzog, D. B., Franko, D. L., & Eddy, K. T. (2017). Will I get fat? 22-year weight trajectories of individuals with eating disorders. International Journal of Eating Disorders. https://doi.org/10.1002/eat.22690

Egan, A. M., & Collins, A. (2021). Dynamic changes in energy expenditure in response to underfeeding: A review. Proceedings of the Nutrition Society. https://doi.org/10.1017/s0029665121003669

National Center for Health Statistics. (2023). Prevalence of overweight, obesity, and severe obesity among adults age 20 and older: United States, August 2021-August 2023. NCHS Health E-Stats. https://www.cdc.gov/nchs/data/hestat/hestat111.htm

Speakman, J. R., & Hall, K. D. (2023). Models of body weight and fatness regulation. Philosophical Transactions of the Royal Society B. https://doi.org/10.1098/rstb.2022.0231

Speakman, J. R., Levitsky, D. A., Allison, D. B., Bray, M. S., de Castro, J. M., Clegg, D. J., et al. (2011). Set points, settling points and some alternative models: Theoretical options to understand how genes and environments combine to regulate body adiposity. Disease Models & Mechanisms, 4(6), 733-745. https://doi.org/10.1242/dmm.008698

If someone eats 1,500 calories a day, that’s a diet.

If someone eats 1,000 calories a day, that’s a strict diet.

If someone eats 500 calories a day, maybe (?) that’s starting to sound concerning?

If someone eats nothing at all, that’s an eating disorder? ( Or maybe they’re just fasting)

I keep thinking about how we pretend these are different categories, separated by clear lines. Our culture claims that they are, despite our lack of agreement on where those lines are. And these lines are arbitrary, cultural, and constantly shifting depending on whose body is doing the restricting and how well the suffering has been disguised as self-improvement.

Even Ariana Grande, whose visible emaciation is being debated instead of named, illustrates how the culture cannot bring itself to call starvation what it is even when the clinical markers are unmistakable.

But that is one extreme end of one continuum.

There is a running joke that RuPaul uses where someone is offered a single tic tac for dinner because they are “watching their figure.” It lands as a joke because the audience recognizes the premise: eating practically nothing is what real discipline looks like. We are supposed to laugh at the exaggeration, but the exaggeration is barely an exaggeration. The joke only works because the culture has already normalized the idea that a tic tac sized portion is a reasonable aspiration.

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I think about this every time I watch The Devil Wears Prada. In the opening montage, a model-looking woman counts out exactly six almonds into a little dish for breakfast . And there is Emily, later, describing how she does not eat until she gets so hungry that she eats a single cube of cheese, played as a funny character quirk. No one in the movie treats any of this as remarkable or alarming. It is just what disciplined people do. People who want to be thin. Scenes of restriction played as character details, not warning signs. There is no metric for when discipline becomes pathology, just like there is no metric for when a body is thin enough.

I remember being in my twenties and on Weight Watchers, back when there was a Points system, one of many. My boyfriend was away on a trip for a month, and I was having a rough time. So I literally ate my points in low-point diet chocolate and Diet Coke. For weeks. No actual nutrients. No protein or vegetables. I ate my points and I ate my feelings. At the next Weight Watchers meeting, I told the group what I had been doing. Everyone laughed and clapped at how clever I had been.

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So when does disordered eating become an eating disorder?

Tylka and Subich (1999) wanted to know whether eating pathology exists on a spectrum or in distinct categories. They measured things like drive for thinness, body dissatisfaction, and neuroticism in women with no eating concerns, women with some symptoms, and women with clinical eating disorders. The scores did not cluster into separate groups. They increased steadily and predictably from one group to the next. The women with the most severe symptoms were not experiencing something fundamentally different from the women with mild symptoms. They were experiencing more of the same thing.

This finding should unsettle us, because it means the behaviors that clinicians recognize as risk factors for eating disorders are the exact same behaviors diet culture sells as wellness. Restriction gets relabeled as intermittent fasting. Food fear becomes “clean eating.” Obsessive tracking becomes being “on top of your health.” The language might change, but the behavior does not.

And the behaviors do not just shift in name. They cycle. People skip meals so they can eat more later. They restrict all week so they can binge on the weekend. They feel guilty about the binge, so they restrict harder. All of these are flavors of the same thing. The binge is not the opposite of the restriction. It is the consequence of it.

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This spring, TikTok banned #SkinnyTok after European regulators raised concerns about the platform promoting unrealistic body images and extreme weight loss. The hashtag ban helps at the edges, but the content does not vanish. It renames itself into clean eating, wellness, lifestyle, and healthy routine content. The algorithm rewards extremes, so the extremes keep coming.

The truth is, we barely even need the hidden corners of the internet anymore. We do not need #SkinnyTok or #proAna content tucked away in obscure forums, because the same ideas are already front and center. They are the main feed, not the dark web.

A dietitian interviewed about the trend described meeting teenage girls terrified of foods as benign as bananas. Girls who had already lost their periods from lack of eating. Girls with severe digestive issues from weeks of undereating. All because someone on TikTok told them that 600 to 800 calories a day is a health goal (Soigné Middle East, 2025).

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Eating disorders diagnosed according to DSM-5 criteria affect only a small percentage of the population. Swanson et al. (2011) found lifetime prevalence estimates of 0.3% for anorexia, 0.9% for bulimia, and 1.6% for binge eating disorder in a nationally representative sample of over 10,000 adolescents.

But when Hay et al. (2023) measured more broadly defined eating disorders in an Australian sample, the number jumped to around 16% in females. And when they measured disordered eating (behaviors like restriction, food guilt, compulsive exercise, body preoccupation), the estimate climbed to 25.7% of adolescent females.

Some research suggests as many as 75% of women in America have symptoms of disordered eating (Ellis-Ordway, 2021).

The difference between 2% and 25% and 75% is the gap between what we are willing to diagnose and what people are actually experiencing. Most of that gap is filled with behaviors the culture actively encourages.

Hesse-Biber et al. (2006) called this “culturally induced eating” (a pattern where individuals display the behavioral symptoms of eating disorders without the full psychological profile associated with clinical cases) and noted that these behaviors are “largely considered normative behavior for women” and remain “largely unproblematized or altogether ignored by a clinical perspective.“ In other words, you can do all the things someone with an eating disorder does, as long as you do them without the right diagnosis. And the culture will not just tolerate it, it will reward you for it.

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I think about this a lot in relation to food noise, the constant mental chatter about eating that people on GLP-1s suddenly noticed when it stopped, and how the term went viral only after there was something to sell. The same culture that tells you to restrict is the one that profits from the consequences of that restriction.

The same culture that broadcasts 800-calorie days as aspirational content is the one that acts surprised when people develop eating disorders.

I do not think the line between disordered eating and eating disorders is meaningless. Diagnosis matters for treatment access, for insurance coverage, for medical care. But culturally, that line has become a hiding place. We treat eating disorders as rare pathologies affecting a small number of people, while the behaviors that create them are everywhere.

Seventy-five percent of women in America have symptoms of disordered eating (Ellis-Ordway, 2021). Three out of four. That is not a fringe population or a vulnerable subset. It is the norm.

And the culture that produced that number is not going to tell us when we have crossed the line, because the line was never meant to protect us. It was meant to keep us wondering whether we have earned the label of “health” yet.

So how do you know?

If there is no weight at which the culture will say you are thin enough, and no point at which it will say your discipline has gone too far, then the only person who can set that boundary is you. And that is an unsettling place to be left, because most of us have never been asked to decide for ourselves where health ends and where harm begins.

References

Brown, H. A., & Ellis-Ordway, N. (Eds.). (2021). Weight bias in health education: Critical perspectives for pedagogy and practice. Routledge.

De Sarkar, M. (2025, May 7). SkinnyTok, “clean” anxiety & DIY acid peels: This clinical dietitian pulls the plug on viral wellness. Soigné Middle East. https://soignemiddleeast.com/2025/05/07/skinnytok-dangers/

Hay, P., Aouad, P., Le, A., Marks, P., Maloney, D., & the National Eating Disorder Research Consortium. (2023). Epidemiology of eating disorders: Population, prevalence, disease burden and quality of life informing public policy in Australia, a rapid review. Journal of Eating Disorders, 11(1), 23.

Hesse-Biber, S., Leavy, P., Quinn, C. E., & Zoino, J. (2006). The mass marketing of disordered eating and Eating Disorders: The social psychology of women, thinness and culture. Women’s Studies International Forum, 29(2), 208-224.

Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents. Archives of General Psychiatry, 68(7), 714-723.

Tylka, T. L., & Subich, L. M. (1999). Exploring the construct validity of the eating disorder continuum. Journal of Counseling Psychology, 46(2), 268-276.

Europeans tell it with a very specific satisfaction, a way of saying at least we are not that . Americans tell it on themselves, a self-deprecating shrug that somehow still functions as a judgment on someone else.

On the Fourth of July especially, the joke is practically ceremonial. America celebrates its independence with an orgy of food, burgers and hot dogs and potato salad and pie, and then uses that same abundance as evidence of its own moral failure. We would never look at a Jewish family sitting down for a Passover seder or a Rosh Hashanah dinner, holidays where the entire celebration revolves around food, and say see, this is why they are all fat. But when it is America’s body on the table, the judgment is automatic. The food becomes proof of gluttony rather than tradition.

But what are we actually saying when we say America is fat?

The word fat is doing more work than it looks like, and not the work it pretends to be doing. It is code for undisciplined, for bad choices, for probably poor and probably not white and probably not someone whose judgment I need to take seriously. The word collapses all of those judgments into one syllable that pretends to be just a reflection of body size.

What do you automatically think about when you think about fat?

The standard assumptions are something about choices, discipline, willpower, maybe sometimes access if someone is aware enough.

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But to make a joke that the whole country is fat? What is that really saying at its core?

Discipline is the operating principle of white Christian nationalism in America. The Puritan work ethic taught that your body reflects your relationship with God. By the late 19th century, Protestant reformers saw fatness as an outward sign of gluttony and a poor relationship with God, while thinness demonstrated the restraint and discipline that salvation required (Farrell, 2011). The Protestant work ethic pushes the idea that individuals reap what they sow. Fat people, in this frame, have reaped what they planted with their own poor choices (Pause, 2018; Crandall, 1994).

Sociologist Sabrina Strings traced this directly to the transatlantic slave trade and the spread of Protestantism, where fatness was coded as Black, primitive, and sinful while thinness was coded as white, civilized, and morally upright (Strings, 2019). Thinness became a condition of citizenship and elite belonging, a way to mark who counts and who does not .

The class version is the same logic. Poor people are fat because they lack the discipline to make better choices. Ignore the fact that the food environment engineered for profit, the stress response that drives fat storage, the whole system designed in ways that produce exactly the bodies that then get blamed. The story is simpler: you are fat because you are lazy. You are poor because you are lazy. These are the same judgment just wearing a different hat.

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We broadcast those bodies, headless, as a constant warning sign about our “obesity epidemic”. Fat activist Charlotte Cooper coined the term headless fatty to describe the photographs that illustrate nearly every news article about obesity in America: a fat body, photographed without consent, head cropped out of frame. Faceless, they have been reduced to a stomach, an arm, a backside. Researchers at Yale’s Rudd Center found that 72% of images used in online news stories about obesity portrayed fat people in a negative, stigmatizing manner, and fat people were 23 times more likely than thin people to have their heads cut out of the photo (Heuer, McClure, & Puhl, 2011). The image teaches disgust regardless of what the text says. You cannot write a compassionate article about fatness and illustrate it with a headless body.

People of Walmart made this dynamic explicit. The website was built on photographs taken without consent of people in Walmart parking lots and aisles. Almost all of them were fat. Almost all of them were dressed in whatever they could afford or whatever fit. The joke was never really about bad fashion choices. It was about disgust at fat bodies being visible in cheap clothes, proof in the viewer’s mind that the person had let themselves go entirely. The poverty compounded the mockery, but the primary target was the body itself: slovenly, undisciplined, taking up space in public when it should have stayed hidden.

The headless news photo and the People of Walmart snapshot are doing the same work: they take a fat body and turn it into a warning for everyone else. Do not become this. Do not shop here. Do not let yourself go.

Content analysis bears this out. A study of more than 200 news articles found that over 60% blamed obesity on individual choices. Only about 30% discussed any structural factors. When the articles were about Black or Latino people, they were over 13 times more likely to blame obesity on sedentary lifestyles. When they were about poor people, that blame was four times higher (Campos, Saguy, Ernsberger, Oliver, & Gaesser, 2006). The discourse does not target everyone equally. It was never about just body size.

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You would think, given this seemingly universal assumption that America has an obesity epidemic, that we actually do. Right?

AND YET … the science behind the panic about America’s obesity epidemic is remarkably thin (pun intended). In 2006, a team of researchers from law, sociology, nutrition, political science, and exercise physiology examined the four central claims of the war on fat and found limited evidence for every single one (Campos et al., 2006). The data does not show an exponential epidemic.

The entire population-level rise in average weight could be explained by a daily surplus of roughly 10 calories per person, less than two pieces of gum. Enough to shift a bell curve, not enough to justify the language of crisis.

Part of what looks like a dramatic rise is a definition change, not a body change. In 1998, the NIH lowered the BMI threshold for “overweight” from 27 to 25. Overnight, roughly 50 million more Americans were reclassified as overweight without gaining a single pound (Boero, 2003). The goalposts moved, but the bodies did not.

Even the core claim, that higher body weight means higher mortality, does not hold up the way we have been told. A 2013 meta-analysis in JAMA pooled 97 studies with nearly 3 million people and found that overweight (BMI 25–30) was actually associated with lower all-cause mortality than “normal” weight. Grade 1 obesity (BMI 30–35) showed no significant mortality difference at all (Flegal et al., 2013). The category that qualifies over a third of Americans for a medical diagnosis does not, at the population level, clearly predict higher death rates.

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Gard and Wright (2005) observed that people who talk about the obesity epidemic often adopt a tone of absolute conviction, as though both the extent of the problem and its causes are self-evident. The conviction is the point. We ignore the lack of data because the story feels true.

There is what is factually true, and there is what is emotionally true, and they are not the same thing. Factually, the data does not support the story. The rise in average body weight is modest, the link between BMI and health is weak, and shaming people does not make them thinner. But emotionally, the story still feels true.

The emotional “truth” is that thin people work harder, that weight is earned, that fatness is failure made visible. And human beings do not make decisions from spreadsheets. We make them from fear, belonging, shame, pride, and identity (Walsh et al., 2022).

You can show someone a study proving that weight stigma predicts higher cortisol, more binge eating, and worse health outcomes, but if their emotional truth says that shaming people is the only thing that works, the data will not move them. Because stories engage cognitive processes that facts do not, triggering personal experience and narrative transportation that can reduce resistance to controversial information in ways that undiluted data cannot (Ma, 2020; Green & Brock, 2000).

Because it is useful. And because its emotional truth is a story being shouted much more loudly and convincingly than the data.

And the emotional truth that we are being sold is that fat is bad, weak, undisciplined, perhaps even, unmanly?!

Consider the current administration, which is basically a middle school art project on manliness. Pete Hegseth, who has never served in the military, declared he was tired of seeing “fat troops” and replaced soldiers based on a photograph. He posts workout videos that go viral, not for his fortitude, but for how inept he looks working out. The man lecturing the military on physical standards cannot meet the standards himself, but he’s thin, which makes him believe that IS the standard. Which only serves to prove that the standards have nothing to do with actual capability.

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And then there is the way the word “fat” itself moves through the culture. Trump has spent decades using “fat” as a slur against Chris Christie, Rosie O’Donnell, against his own supporters, against the federal government itself. The people who hate Trump return the favor, doubting his reported weight, calling him obese, using his body as evidence of his moral and physical unfitness.

Both sides throw the same word at each other and nobody stops to ask whether the word itself is doing the damage regardless of who wields it. “Fat” is never neutral when applied to an (American) body. It is always a judgment, always a dismissal, always shorthand for undisciplined, worthless, less than. The left uses it to prove Trump is unfit. The right uses it to prove the poor are lazy. The word just keeps doing its work no matter which mouth it comes out of.

If people were worried about America being fat, they would be asking different questions.

They would be asking why corporations are allowed to engineer foods that override appetite regulation, why the most available calories are the cheapest and most processed, why we are okay with the living wage not allowing people to live, why the stress of living in a country that maximizes profit and minimizes structural support produces the very bodies that are then blamed for existing (Guthman, 2011; Swinburn et al., 2011; Tomiyama, 2014).

They would be pushing against corporate power, not against fat people.

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But that is not the story we keep repeating within our culture.

This is what Thick Me Up is about. Changing the story, not just debunking the statistics. Because every time someone tells the fat American joke, they are contributing to this machine. They are buying into the idea that discipline determines worth, that poor people deserve their poverty, that fatness is failure made visible, that the body is a moral ledger. They are reinforcing white Christian nationalism, patriarchy, racism, class hierarchy, and a centuries-old tradition of using the body to sort people into worthy and unworthy.

The data was never going to stop it.

Stories do not lose to facts. They lose to better stories.

So this Fourth of July, maybe we should stop laughing at the joke of the fat American and start telling a better story instead.

That is what liberation looks like.

References

Boero, N. (2003). All the news that’s fat to print: The American “obesity epidemic” and the media. Paper presented at the American Sociological Association Annual Meeting, Atlanta, GA.

Campos, P., Saguy, A., Ernsberger, P., Oliver, E., & Gaesser, G. (2006). The epidemiology of overweight and obesity: Public health crisis or moral panic? International Journal of Epidemiology, 35(1), 55–60.

Cooper, C. (2007). Headless fatties. Retrieved from https://charlottecooper.net/fat/headlessfatties/

Crandall, C. S. (1994). Prejudice against fat people: Ideology and self-interest. Journal of Personality and Social Psychology, 66(5), 882–894.

Farrell, A. E. (2011). Fat shame: Stigma and the fat body in American culture. NYU Press.

Flegal, K. M., Kit, B. K., Orpana, H., & Graubard, B. I. (2013). Association of all-cause mortality with overweight and obesity using standard body mass index categories: A systematic review and meta-analysis. JAMA, 309(1), 71–82.

Gard, M., & Wright, J. (2005). The obesity epidemic: Science, morality and ideology. Routledge.

Green, M. C., & Brock, T. C. (2000). The role of transportation in the persuasiveness of public narratives. Journal of Personality and Social Psychology, 79(5), 701–721.

Guthman, J. (2011). Weighing in: Obesity, food justice, and the limits of capitalism. University of California Press.

Heuer, C. A., McClure, K. J., & Puhl, R. M. (2011). Obesity stigma in online news: A visual content analysis. Journal of Health Communication, 16(9), 976–987.

Ma, Y. (2020). The power of storytelling: Shifting attitudes and pro-social feelings. Journal of Communication.

Pause, C. (2018). Die another day: The obesogen environment and the fight for fat liberation. In The Routledge international handbook of fat studies (pp. 142–154). Routledge.

Puhl, R. M., Peterson, J. L., DePierre, J. A., & Luedicke, J. (2013). Headless, hungry, and unhealthy: A video content analysis of obese persons portrayed in online news. Journal of Health Communication, 18(6), 686–702.

Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. NYU Press.

Swinburn, B. A., Sacks, G., Hall, K. D., McPherson, K., Finegood, D. T., Moodie, M. L., & Gortmaker, S. L. (2011). The global obesity pandemic: Shaped by global drivers and local environments. The Lancet, 378(9793), 804–814.

Tomiyama, A. J. (2014). Weight stigma is stressful: A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite, 82, 8–15.

Walsh, J., Vaida, N., Coman, A., & Fiske, S. T. (2022). Stories in action: Engagement, identification, and meaning construction. Psychological Science in the Public Interest, 23(2), 54–82.

I had spent weeks looking for a primary care physician. When you’re fat, that search is stupidly difficult. You’re not just checking which doctors are taking new patients, or which doctors take your insurance. You’re trying to find someone who will actually see you. Who won’t walk into the room and see your weight before they see you. Who won’t attribute every symptom you have to the fact that you’re fat. Who won’t tell you to lose thirty pounds before they’ll order a basic blood panel.

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So you do what fat people do. You go online. You search Reddit threads and TikTok comments and Facebook groups and Health at Every Size directories and you try to find someone who might be safe. I found a name on Reddit: Dr. Carolyn Hammett, at MedStar in Maryland. She was even listed at fatfriendlydocs.com. Relying on the other people who said that she was fat-friendly, someone who wouldn’t just see a number when you sat on the exam table. I made an appointment.

She didn’t have availability for a while, because we live in America, and I needed to see someone before she had an opening. So I saw another doctor at the same practice. When I went for that appointment, I declined to be weighed, and that was it. No pushback. No lecture. He just moved on with the appointment, and I remember thinking this practice might actually be fine.

So today I finally get in to see Dr. Hammett, the doctor I came to MedStar for. They were having problems with their systems, so I end up waiting about thirty minutes before I get called back by a physician’s assistant, who immediately asks me to get on the scale. I say, “No, thanks.” She says, “I’m sorry, excuse me?” in kind of an aggressive way and I say, “No, thank you. I don’t need to be weighed.” She tells me they need my weight because they need my BMI, and I tell her that BMI is a bad individual indicator for health and it was invented by an astronomer in the nineteenth century.

She goes, “Well, that’s your belief.”

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I know that in the contemporary Trump world there is a whole lot of narrative about truth versus beliefs, but who invented the BMI is not my belief. It’s just a fact. It’s not like I was telling her what I thought of the second season of House of the Dragon. It’s not an opinion. The BMI was invented by an astronomer.

She says Dr. Hammett is gonna have a really big problem with my refusing to be weighed, and I tell her that’s fine, I’m happy to talk to the doctor about it. In my head, even though I’m already thinking this is going about as badly as it could go, perhaps it’s just this individual person working in the office.

So Dr. Hammett comes in, and she’s a fat woman, and I want to be clear that her being a fat woman doesn’t necessarily mean she’s not gonna be fatphobic, because a lot of people have such internalized weight stigma that some of the most fatphobic people are fat. But at least it meant, I thought, that she might “get it.” Somebody who has a lived experience as a fat person might be somebody who has more empathy and more understanding, even though obviously internalized weight stigma is very real and it runs very deep, and unfortunately the medical system feeds it constantly.

So the very first thing that she asks me is why I don’t wanna be weighed. And I say to her exactly the same thing I’m saying to you: my weight is not a predictor of what my health is, and it’s not really important for her to have as a data point. And she says that MedStar requires that I be weighed.

Apparently, MedStar rates doctors on their ability to collect vitals from patients? Which, is disturbing on a whole other level, but I digress.

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And I say to her, “I’ve been here before, and I saw another doctor, and I declined to be weighed, and they said it was fine.” And she responds, “Well, then why aren’t you seeing that other doctor?” To which I remind her that I literally came to MedStar to SEE HER. I looked up a doctor who was fat-friendly, and the internet pointed me to HER.

And she says, “Is it because I’m fat?” And I say, “No, it’s because somebody had an experience with you where they said that you were not a person who just judged people based on their weight.”

Then she says, “I don’t think we’re gonna get along.”

That was her response.

I asked if she was ever a fat-friendly doctor. She said, “Maybe before I came to MedStar.”

She said we weren’t going to get along a second time, and she just leaves the room.

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So essentially, I’m not going to be seen, not going to be a patient of hers, because I advocated for myself, because I didn’t wanna be weighed, because I’m so fucking non-compliant. I did actually ask her if she personally believed in the BMI, and she said no.

A doctor who was recommended to me as fat-friendly, who is fat herself, refused to treat me because I declined to be weighed. Because I advocated for myself.

And the whole thing rests on a lie. The lie that excess weight comes from poor health habits. That if you are fat, it is because you are doing something wrong, and the solution is to fix what you are doing. There are many pathways to a larger body, and I’ve written about them before . The short version: there are medical conditions that cause weight gain and do not respond to diet or exercise. There are medications that cause weight gain. There are genetics, trauma, metabolic histories, and a thousand other pathways to a larger body that have nothing to do with what you ate for lunch.

And the medical system knows it. Researchers have been publishing evidence about the many pathways to fatness for decades. But knowing better and doing better are not the same thing. The system has a single story, and the single story is: you are fat because you are doing it wrong . And if you are doing it wrong, then the solution is compliance. Change your habits, your relationship with food. Lose the weight. Take the drug. Do what you are told. And if you do not, you are non-compliant.

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The question I keep coming back to is this: if Dr. Hammett would not even see me without first knowing how much I weigh, how could I believe that any decision she makes about my care is not filtered through that number?

Weight is never just sitting quietly in your chart once it gets there.

The AMA Journal of Ethics has written that BMI shapes diagnostic workup, diagnosis, intervention selection, and outcome measurement (American Medical Association, 2023). In plain language, that means the number can steer how future doctors interpret your symptoms, which treatments they consider, and how they frame your care before they even ask what is wrong.

The idea that weight is an important data point, at the very least for a baseline, also doesn’t hold up to scientific rigor. There are only a few situations where your weight is medically necessary for treatment: chemotherapy dosing, certain heart conditions, anesthesia, dialysis. Everything else your doctor does in a routine visit is not weight-dependent, even though we have been taught to believe it is.

People have essentially been taught to believe that if your weight changes, your blood pressure will change, your heart rate will change, and everything else will follow because weight is such an important number. But the science shows that weight does not actually drive those numbers (Mann et al., 2005). Blood sugar, cholesterol, mood, mobility, sleep, energy, none of those things automatically change just because your weight changes.

The only thing your weight reliably predicts… is your weight.

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The AMA itself is saying that BMI is broken. At the 2023 Annual Meeting, the House of Delegates adopted a policy acknowledging the “significant limitations” of BMI in clinical settings, noting that it “loses predictability when applied on the individual level” and that it was developed from data collected primarily on non-Hispanic white men (American Medical Association, 2023). Far from a fringe opinion, this is the largest association of physicians in the country saying the tool they’ve been using for decades does not work the way they thought it did.

And yet, we are still mandated to be weighed. To have our BMIs calculated like little fat automatons. We are still supposed to let that number sit in our chart and shape how every future doctor sees us, because that is how it has “always” been done. Even though using the BMI only came back into practice in the 1980s (Pray & Riskin, 2023).

But it is now 2026.

If I can take the time as a non-medical doctor, just a person with Google Scholar, to look up and educate myself about what science actually says about weight stigma, about BMI, about the difference between correlation and causation, why can’t my doctor?

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What is the expectation here? That if I show up and step on a scale, I am just going to sit back and let that number do the thinking for both of us? The research on weight stigma is not hidden. It is not new. Weight discrimination is associated with higher rates of depression, anxiety, exercise avoidance, and chronic stress, independent of actual BMI (Puhl et al., 2020; Tomiyama et al., 2018). Even the American Association of Clinical Endocrinology has acknowledged that weight stigma is detrimental to health and is related to higher morbidity and all-cause mortality (Nadolsky et al., 2023). As my doctor, if my health is in your hands, engaging with the current research and evidence is not a higher standard. It is the standard.

So why is getting my weight somehow mandatory? Why is it collected whether I want it or not? Why is my doctor refusing to treat me when I decline to be weighed?

Because fat people are expected to comply. That is the word that keeps coming back to me, and it is the word the medical system uses for people like me: non-compliant. There is an acronym used within some medical settings called HONDA, which stands for Hypertensive, Obese, Non-compliant, Diabetic, Asthmatic.

Read that list again. And notice what the acronym does before a doctor has even spoken to you. It assumes that because you are obese, you are also hypertensive, diabetic, and asthmatic. Three conditions diagnosed without a single test. Non-compliant sits next to diseases. The medical system has classified a fat person who asks questions as a “failure” alongside hypertension and diabetes. Not because something is wrong with her body, but because she isn’t just smiling, nodding, and complying.

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I found the Reddit thread where I first saw Dr. Hammett’s name. It was posted by a fat person in Baltimore asking for a fat-friendly primary care provider. The responses were exactly what you would expect: most people recommended someone.

But then a doctor showed up in the comments to explain that what the OP was really asking for was a doctor who would ignore their health. “If you’re asking for a doctor who will condone excess weight and poor health habits, then they’re not a good doctor.” The assumption baked into that sentence is that excess weight comes from poor health habits. That fatness is a behavior problem with a behavior solution. And that any doctor who does not start from that premise is failing at their job.

And this is not just one doctor in a Reddit comment.

Weight bias in the medical field is rampant. A national study of first-year medical students found that 74% exhibited implicit weight bias, which means the majority of them did not even realize they had it (Phelan et al., 2014). A separate study of 2,284 medical doctors found strong implicit anti-fat bias at levels comparable to racial bias (Sabin et al., 2012). So it is not a couple of bad doctors. It is the entire medical profession deeply rooted in fatphobia before a single medical textbook even entered the room.

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Now, one person in the thread described herself as a compliant fat person.

That is the compliance trap. You can do everything right, eat everything right, move your body the way they tell you to, and it still doesn’t matter. Because the goal was never your health. The goal was your weight. And there is no version of compliance that protects you when the thing being measured is not your health but your size.

The compliance trap is everywhere. There is the compliance to GLP-1 drugs, where 44% of patients report nausea and 24% experience vomiting (Wilding et al., 2021). The cultural message is clear: your body is so unacceptable that permanent nausea is a reasonable trade. There is the compliance to beauty standards, to clothes not made in your size, seats not built for you, planes and restaurants designed for someone smaller. You comply by smiling, by not making a fuss, by apologizing for taking up room.

When you stop complying, even once, even gently, even by just saying “no thanks” to a scale, you are labeled non-compliant. Difficult. A problem.

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I could have just been weighed. I could have had my BMI put in the chart with the rest of my information and moved on. What I am trying to work towards within Thick Me Up is this idea that by continuing to smile and go along with fatphobic practices, within medicine and within society, we are contributing to the problem.

~~~This broken system relies on our compliance, our complicity.~~~~

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So if not being weighed makes me “non-compliant” and a problem, then yes, I am going to be a problem. Because no important change in history started with people sitting down and shutting up. Not Stonewall. Not the Greensboro sit-ins. Not the 504 sit-in. I understand that being called a problem sounds like an issue, except when it’s the sound of the status quo changing, and it matters in this case.

So I will refuse the scale. I will question the BMI. I will make doctors uncomfortable when I ask them to treat my actual symptoms instead of my body size. And I am not going to apologize for it, because fat people have been apologizing for taking up space in a doctor’s office for long enough.

If you have ever left a doctor’s office feeling unseen, dismissed, or like you were the problem instead of the person with the problem, this is your story too.

I know there are people reading this, or watching the video , who think that I made a fuss needlessly. Who think I should have just been weighed, just complied, just made it easy. I want those people to stop for a second and ask yourselves why.

Why is being weighed so non-negotiable? What do you think it is actually doing? Is this about my health, or is it about policing my body the way you have been taught to police your own? What have you been told that weight is so integral to that a fat person saying no to a scale feels like a threat?

And most importantly, what if the science you were told to uphold your beliefs about fat being bad is outdated and incorrect? Would that change your mind?

Because I did not refuse treatment, I asked for treatment. I showed up calm and respectful and said no to one thing and asked why. And a doctor refused to see me for it.

The system is broken, and no one but us is here to fix it. I’m committing to be a part of the fixers.

This is Thick Me Up.

References

American Medical Association. (2023). AMA adopts new policy clarifying role of BMI as a measure in medicine. https://www.ama-assn.org/press-center/ama-press-releases/ama-adopts-new-policy-clarifying-role-bmi-measure-medicine

Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2005). Medicare’s search for effective obesity treatments: Diets are not the answer. American Psychologist, 62(3), 220-233.

Nadolsky, K., Addison, B., Agarwal, M., et al. (2023). American Association of Clinical Endocrinology consensus statement: Addressing stigma and bias in the diagnosis and management of patients with obesity. Endocrine Practice, 29(7), 587-597. https://doi.org/10.1016/j.eprac.2023.03.272

Phelan, S. M., Dovidio, J. F., Puhl, R. M., Burgess, D. J., Nelson, D. B., Yeazel, M. W., Hardeman, R., Perry, S., & van Ryn, M. (2014). Implicit and explicit weight bias in a national sample of 4,732 medical students: The medical student CHANGES study. Obesity, 22(4), 1201-1208. https://doi.org/10.1002/oby.20687

Pray, R., & Riskin, S. I. (2023). The history and faults of the body mass index and where to look next: A literature review. Cureus, 15(11), e48230. https://doi.org/10.7759/cureus.48230

Puhl, R. M., Lessard, L. M., Larson, N., Eisenberg, M. E., & Neumark-Stzainer, D. (2020). Weight stigma as a predictor of distress and maladaptive eating behaviors during COVID-19: Longitudinal findings from the EAT study. Annals of Behavioral Medicine, 54(10), 738-746. https://doi.org/10.1093/abm/kaaa077

Sabin, J. A., Marini, M., & Nosek, B. A. (2012). Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS ONE, 7(11), e48448. https://doi.org/10.1371/journal.pone.0048448

Tomiyama, A. J., Carr, D., Granberg, E. M., Major, B., Robinson, E., Sutin, A. R., & Brewis, A. (2018). How and why weight stigma drives the obesity ‘epidemic’ and harms health. BMC Medicine, 16, 123. https://doi.org/10.1186/s12916-018-1116-5

Wilding, J. P. H., Batterham, R. L., Calanna, S., et al. (2021). Once-weekly semaglutide in adults with overweight or obesity. New England Journal of Medicine, 384(11), 989-1002. https://doi.org/10.1056/NEJMoa2032183

I want you to take a moment and sort of … extrapolate what that actually means at scale. That this simple explanation, this “if only they did X” justification, would need to cover an ENORMOUS volume of people. More than half the global adult population is overweight or obese (WHO, 2024). To believe that all of them, across every country and culture and generation, have the same problem and that’s why they’re fat requires ignoring a lot of what we know about how bodies work.

Understand that for this group of 2.5 billion people, you’d be telling me that they all just don’t have good habits. Like they all just don’t understand their relationship to food. And being fat is all their fault.

How is that even remotely logical or possible?

The reason the challenge lands is that it asks people to say out loud what they already believe.

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Most people will not say “all fat people lack discipline” when asked directly because they know it sounds cruel. But they will act on that assumption in a thousand smaller ways: in the advice they give, in the judgments they make, in the insurance policies they design, in the treatments they offer and the ones they withhold. You can feel it in the way a person looks at a larger person at the grocery store on a mobility scooter. In the way your seatmate on a plane sighs before you have even sat down. In the way people watch a fat person eating at a restaurant, as if the act of eating itself is evidence. The judgment arrives before you do. The belief does not need to be spoken aloud to be operational.

These biases are baked into policies, into penalties . Within our society, you might not realize just how much heavy lifting they’re doing.

What makes this so hard to unravel is that the single-story approach to fatness is not just wrong in the way an incorrect fact is wrong. It is wrong because the human body is not one thing with one cause. Bodies get fat through so many different pathways that the idea of a unified explanation becomes almost comical once you start listing them.

By no means an exhaustive list, but there is lipedema (Buck & Herbst, 2016), a condition affecting roughly 500 million women worldwide where fat is genetically distinct from ordinary body fat (Child et al., 2010) and does not respond to diet or exercise or bariatric surgery. The average time from symptom onset to diagnosis is 15 years, and many women are never diagnosed at all, only stigmatized. One Swedish national study found that while nearly 70% of women with lipedema experienced onset before age 30, only 1.6% had been diagnosed by a healthcare professional before that age (Falck et al., 2022).

There is polyendocrine metabolic ovarian syndrome, PMOS, the new name for what was previously called polycystic ovarian syndrome, PCOS, and the name change itself says something: this is not a condition limited to the ovaries. PMOS is a systemic endocrine and metabolic disorder affecting an estimated 8 to 13% of women of reproductive age, characterized by insulin resistance, hyperandrogenism, and metabolic dysfunction that directly affect body weight regulation(Azziz et al., 2016; Teede et al., 2026). The condition runs in families and has a strong genetic component. Weight gain and difficulty losing weight are physiological consequences of this hormonal profile, not evidence that someone lacks discipline or a good relationship to food. And yet, like lipedema, PMOS is routinely dismissed or simply missed, leaving women to be told they just need to eat less and exercise more. Or worse, in order to better the condition, they are told to lose weight. The very thing the condition makes difficult.

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There are medications that cause weight gain as a direct pharmacological effect. I know this from my own body, and the effect that the insistence on a single story had on me: it makes you feel like a failure even when your body is doing the hardest thing it has ever done.

When I had stage 4 skin cancer, the immunotherapy drugs I took triggered serious immune responses in my body. To combat those, I was put on prednisone at 180 milligrams every day. For context, a “high dose” of prednisone for most conditions is 40 to 60 milligrams. I was on three times that (the highest legal dose you are allowed to have), because it was the only thing keeping me from getting a hole in my colon. And it made me gain weight so fast. I had been the same weight for probably ten years, same level of activity, same everything. But here I was, just gaining and gaining. And I was so upset about it that I was barely registering that my body was fighting cancer and beating it. I was upset because I was gaining weight and I felt like I was failing. Add to that, everyone’s assumption when they hear you have cancer is that you are wasting away! That is the mental image. But here I was, gaining weight on the treatment that was saving my life. So I was not even cancering right.

I am not alone. Antidepressants, particularly SSRIs, cause weight gain. Antipsychotics, particularly second-generation ones, cause weight gain. So do steroids (like prednisone), beta-blockers, and insulin therapy itself. The mechanisms are known and well-documented. People who gain weight on these medications are not failing at discipline. They are experiencing a predictable physiological response to a drug they need.

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There are genetic conditions that affect body weight directly. Congenital leptin deficiency. Mutations in the melanocortin-4 receptor pathway. Prader-Willi syndrome. There are people born into families where every generation on one side has the same body type, where being fat is not an accident of lifestyle but an inherited trait as clearly as eye color. Twin studies have consistently found that body weight heritability ranges from 40 to 70% (Maes et al., 1997). That does not mean weight is fully determined by genes. It means the idea that everyone starts from the same baseline and diverges only through effort (or lack thereof) is not supported.

There is set point biology, the body’s tendency to defend a particular weight range through hormonal signaling, metabolic adaptation, and changes in energy expenditure. People who lose significant weight experience declines in resting metabolic rate that persist for years after the loss, long after any plausible explanation about “smaller bodies needing fewer calories” can account for the magnitude of the effect (Fothergill et al., 2016). Even at the cellular level, adipose tissue retains an epigenetic memory of obesity after weight loss, suggesting the body remembers its higher weight long after that weight is gone (Hinte et al., 2024). The body fights to regain what it lost, not because the person lacks discipline, but because the system is designed to resist starvation.

There is trauma, which changes the body’s stress response systems and alters cortisol regulation in ways that promote fat storage, particularly visceral fat (Dickerson & Kemeny, 2004; Tomiyama, 2014). There is poverty, which limits access to nutritious food and creates chronic stress and makes it harder to exercise when you work multiple jobs and live in a neighborhood without safe places to be active. There is food environment, the fact that for millions of people the most available calories are the cheapest and most processed ones, not because of poor choices but because of structural realities (Swinburn et al., 2011).

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People love to laugh about America being fat, as a blanket disdain. They tell the joke as if it is neutral , as if the punchline is simply that Americans are lazy or lack discipline. But America is also a place where corporations push unregulated, ultra-processed food into every corner of daily life because it is cheap to produce and profitable to sell (Guthman, 2011). The food environment itself is engineered to override the systems that are supposed to regulate appetite (Kessler, 2009). Meanwhile, we are all too busy pulling ourselves up by our bootstraps to have much energy left to do anything about it.

If trauma causes fatness, if chronic stress alters cortisol and drives fat storage, if poverty limits access to nutritious food and safe places to move, then living in a country designed to maximize profit and minimize structural support may be enough to cause obesity all on its own. What we’re seeing is not a failure of individual discipline. This is a capitalist hellscape. The punchline is not what people think it is.

Despite all of these nuances around fatness and the reasons behind it, they are routinely flattened by a culture that insists the answer is simpler than it is.

What interests me is not just that the single story is wrong. It is what the demand for a single story reveals. If the goal were actually understanding why people are fat, we would welcome complexity. We would want to know about PMOS and lipedema and genetics and medications and trauma and poverty and set point biology, because understanding those mechanisms would let us respond more effectively.

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But that is not what the demand for a single story is about. The demand for a single story is about maintaining blame and shame as the organizing frameworks. If there is one cause, then there is one solution, and if someone has not achieved that solution, it is their fault. Complexity complicates blame. If there are ten different pathways to the same body size and not all of them respond to the same intervention, then you cannot look at a fat person and assume you know exactly what their story is, and that they are at fault.

The GLP-1 conversation keeps circling back to the same trap: there is no version of this where you get to be enough. If you are fat, the expectation is that you should take the drug. That is the solution, the “obvious medical intervention,” the “responsible choice.” But the moment you do, the goal shifts. Now it is too easy, a shortcut, a way of “skipping the real work of healing your relationship with food.” You are not doing it the right way. There is no finish line that stays in place long enough to reach it. The terms of acceptability keep changing precisely because the point is not to settle on a standard that anyone could actually meet. The point is to maintain a system where no body, at any size, is ever just fine.

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The single story persists not because it is true but because it is useful. A population whose bodies are always a little bit wrong, always in need of correction, always just barely failing to try hard enough, is a population that can be managed, sold to, and kept busy chasing a standard that moves the moment anyone gets too close.

But the single story also gives people something even simpler than that: a way to feel superior. It lets you look at a fat person and know, without having to learn anything at all about trauma or genetics or pharmacology that they are less than you. The story does not need to be accurate. It just needs to be available… and it always is.

References

Azziz, R., et al. (2016). Polycystic ovary syndrome. Nature Reviews Disease Primers, 2, 16057.

Buck, D. W., & Herbst, K. L. (2016). Lipedema: A relatively common disease with extremely common misconceptions. Plastic and Reconstructive Surgery Global Open, 4(9), e1043.

Child, A. H., et al. (2010). Lipedema: An inherited condition. American Journal of Medical Genetics Part A, 152A(4), 970–976.

Dickerson, S. S., & Kemeny, M. E. (2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130(3), 355–391.

Falck, J., Rolander, B., Nygårdh, A., Jonasson, L.-L., & Mårtensson, J. (2022). Women with lipoedema: A national survey on their health, health-related quality of life, and sense of coherence. BMC Women’s Health, 22, 521. https://doi.org/10.1186/s12905-022-02022-3

Fothergill, E., et al. (2016). Persistent metabolic adaptation 6 years after The Biggest Loser competition. Obesity, 24(8), 1612–1619.

Guthman, J. (2011). Weighing in: Obesity, food justice, and the limits of capitalism. University of California Press.

Hinte, L. C., Castellano-Castillo, D., Ghosh, A., Melrose, K., Gasser, E., Noé, F., Massier, L., Dong, H., Sun, W., Hoffmann, A., & von Meyenn, F. (2024). Adipose tissue retains an epigenetic memory of obesity after weight loss. Nature, 636(8042), 457–465. https://doi.org/10.1038/s41586-024-08165-7

Kessler, D. A. (2009). The end of overeating: Taking control of the insatiable American appetite. Rodale.

Maes, H. H., Neale, M. C., & Eaves, L. J. (1997). Genetic and environmental factors in relative body weight and human adiposity. Behavior Genetics, 27(4), 325–351.

Swinburn, B. A., Sacks, G., Hall, K. D., McPherson, K., Finegood, D. T., Moodie, M. L., & Gortmaker, S. L. (2011). The global obesity pandemic: Shaped by global drivers and local environments. The Lancet, 378(9793), 804–814.

Teede, H. J., Khomami, M. B., Morman, R., Laven, J. S. E., Joham, A. E., Costello, M. F., et al. (2026). Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: A multistep global consensus process. The Lancet, 407(10545), 2329–2339.

Tomiyama, A. J. (2014). Weight stigma is stressful. A review of evidence for the Cyclic Obesity/Weight-Based Stigma model. Appetite, 82, 8–15.

World Health Organization (WHO). (2024). Obesity and overweight. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

On one level, that argument makes sense. But the evidence people use to support it: the weight doesn’t stay off unless you keep taking it, is being treated as proof that the drug must never stop, when it should be raising a different question. In all existing trials, participants, even those “trying hard,” regained a substantial portion of weight after going off of semaglutide or tirzepatide (Rubino et al., 2021; Aronne et al., 2024).

Weight comes back. Therefore the drug must not stop. “Just take it forever” begins to sound more like a mandate instead of just an option. What tends to go unexamined is how quickly that conclusion becomes treated as self-evident rather than interpretive.

We have started calling obesity a “chronic” disease which makes it easier to lump in with the diseases that necessitate lifelong pharmacological intervention . Sure, that’s nice for trying to reduce bias and discrimination (does it, though?) but it’s weird that it makes obesity a condition is defined primarily by body size rather than a specific malfunctioning system. And even body size is a questionable metric, as we are forced to rely on body-size proxies, most often body mass index (BMI, which is its own problem,) which do not measure pathology (EndoText, 2024; WHO, 2023). Which, to me, makes “lifelong treatment” start to feel inevitable in a way that should invite more skepticism than it does. The GLP-1 cultural explosion has made these tensions impossible to ignore.

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Here is what we actually know.

These drugs have not been used at obesity doses for multiple decades. The FDA approvals for obesity were based on trials lasting roughly 68 to 72 weeks, with limited long-term extension data available. We do not have evidence spanning multiple decades, multigenerational exposure, or detailed data describing physiologic trajectories after many years of continuous use in non-diabetic populations.

And you say, but we have decades of data for GLP-1s for diabetics at their dosage! How different can it be!? Think about trazodone. It was developed as an antidepressant at 300 mg, since it increases serotonin to regulate mood. But at much lower doses, around 50 mg, it does something entirely different: it blocks the chemicals that promote wakefulness, which is why it is widely prescribed off-label for insomnia (Harvard Health Publishing, 2025). Same drug, different dose, a completely different therapeutic effect.

The same principle applies here. We have data on GLP-1s at diabetes doses, but the obesity dose is higher, the population using it is different, and we are acting as though that difference does not matter.

The same is true for who has actually been studied. Most of the clinical evidence we have on these drugs focuses on menopausal and postmenopausal women, if they include women at all. That means the research we have is on a population dealing with very different hormonal dynamics than a 30-year-old with regular estrogen cycling (Borcherds & Skibicka, 2024). Yet GLP-1s are now being prescribed to women of reproductive age with little understanding of how fluctuating hormones might alter the drug's efficacy, side effects, or long-term metabolic or hormonal consequences. Reviews assessing the impact of GLP-1 receptor agonists on women's reproductive health note that safety in pregnancy and effects on fertility, fetal health, and lactation remain unclear, and recommend effective contraception during therapy (Wolszczak et al., 2025). We are, once again, rolling out a treatment at scale before we understand who it is being given to or what the consequences might be.

Let us also consider what it is that we’re signing people up for, forever. Sure, in clinical data trials semaglutide produced average weight losses close to 15% of body weight (Oliver, 2025), and some tirzepatide formulations averaged 20% or more (Aronne et al., 2024), but those were carefully controlled conditions.

Real-world data tells a different story. One recent study found that only around 20% of GLP-1 users will lose the amount of weight described in clinical trials. According to the same study, many patients, roughly 60%, did not lose a clinically significant amount of weight at all. The variability was enormous, ranging from 12.3% to 61% of participants losing at least 10% of their body weight, depending on the cohort and follow-up period (Gasoyan et al., 2024).

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Even the people who do lose weight face a daunting trajectory after the first year. The weight loss people experience in the first year is often not maintained at the same level over four years, and some regain occurs even while still on the medication (Ryan et al., 2024). Add in the fact that if someone weighs 300 pounds, 20% of their body weight is 60 pounds, and they’d still weight 240 pounds and still mostly likely be considered “obese.” And it’s not like there is a guarantee of continued weight loss with long-term use (WHO, 2023).

The way these drugs are discussed has an almost clinical detachment from what they actually do. The side effects reported in trials, nausea in 44% of patients, vomiting in 24%, diarrhea in 30% (Kerlikowsky et al., 2025), are not complications. They are the working mechanisms of the drugs. A drug that suppresses appetite by making eating physically unpleasant is not malfunctioning when it causes nausea. It is working exactly as designed. What allows that to pass as acceptable is not a medical judgment but a prior cultural one: that suffering in a fat body is warranted. Feel sick? Good! Now feel sick forever. Nothing tastes as good as skinny feels, anyway.

But there is a real question of long-term harm that we seem to be glossing over in the service of this “magic” drug. A meta-analysis of 76 trials found GLP-1 use associated with a 37% higher risk of gallbladder disease, more than double in weight-loss trials (He et al., 2022). Gastroparesis is a documented consequence of the same mechanism that makes the drugs work. Thirst suppression means people forget to drink water, and the resulting dehydration can strain kidney function (Richards & Khalsa, 2024). None of this is hidden. And yet when these things happen, the response is not to question the intervention. It is to question the person. Did you take your supplements? Did you remember to drink water? We are systematically teaching ourselves to interpret our bodies’ signals as betrayal , and to willingly take a drug that sabotages this relationship further is, when you think about it, a big ask.

And the discontinuation rates are stark. Among patients with obesity but without diabetes, 64.8% discontinue GLP-1 therapy within a year (Rodriguez et al., 2025). Discontinuation is often driven by gastrointestinal side effects, financial constraints, and limited access through insurance or prescribing guidelines (Budini et al., 2025)

The system the “just take it forever” logic depends on is already cracking.

There is a phrase from addiction medicine that fits uncomfortably well here. Chasing the dragon describes the pursuit of an initial high that becomes progressively harder to reach, requiring more drug and greater risk to approximate an experience that keeps receding. The GLP-1 market is following that same arc. Plateaus are met with escalation, new drugs stacking hormonal pathways engineered to drive deeper and faster weight loss. Clinicians are already naming the red flags: gallstones, muscle loss, the risk of becoming underweight when loss accelerates beyond what bodies can reorganize around (Brookshire, 2026). These warnings aren’t fringe problems; they’re common pitfalls that are being dismissed as trivial in the pursuit of some mythical universal thinness.

The response to these risks follows a familiar pattern. The dangers might be acknowledged, but they are delegated to the umbrella of “personal responsibility.” Use the drugs responsibly, make sure to pair them with resistance training! Make sure protein intake is adequate! In practice, everyone is just accepting that any long-term repercussions experienced by GLP-1 users must be the result of them “using them wrong.”

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The long-term effects remain poorly characterized. Studies show that 20 to 40% of weight lost comes from lean muscle mass rather than fat, particularly when resistance training is insufficient (Oliver, 2025). This matters because loss of metabolically active tissue impairs insulin sensitivity and increases the propensity for rapid fat regain. Energy intake drops by up to 40%, raising serious concerns about deficiencies in iron, calcium, magnesium, zinc, and vitamins A, D, E, K, B1, B12, and C (Kerlikowsky et al., 2025). After one year of treatment withdrawal, participants regain about 60% of the weight they lost, with any metabolic markers consistently rebounding to their original baseline (Budini et al., 2025). A treatment that works while you take it, stops working when you stop, and may leave you worse off after cessation is being treated as worth it. Just part of the experience!

It is also being treated as a new lifestyle choice, and that is where the economics become impossible to ignore. Novo Nordisk reported over $20 billion in revenue from Ozempic and Wegovy combined in 2023. Eli Lilly’s tirzepatide products generated billions within their first year of expanded obesity indications. Global GLP-1 sales are projected to exceed $100 billion annually within the next decade (Grand View Research, 2024). A medication taken indefinitely is not just a treatment. It is a recurring revenue stream.

But the system cannot actually sustain the commitment it is asking people to make. In October 2025, the Howard County Public School System in Maryland announced it would stop covering GLP-1s for weight management. In 2023, it had spent $1.6 million covering the drugs for 263 employees. Nine months into 2025, the cost had jumped to $8.2 million for 1,144 prescriptions (The Banner, 2026). District officials said that without dropping coverage, premiums would have risen nearly 20%. Across the country, a KFF survey found nearly two-thirds of large employers said covering GLP-1s had a significant impact on their drug costs. GoodRx estimated that 12 million people lost coverage for Zepbound and 12 million for Wegovy (Lupkin, 2026). The pattern is structural. Coverage appears, then recedes. People start a medication expecting lifelong use, and then the rug is pulled. The “just take it forever” logic assumes a stable system. There is nothing stable about this.

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And even as people are asked to tolerate all of this, the target is shifting. Now that thinness is allegedly within reach, thinness alone is no longer enough. The goal has become toned, athletic, muscular. I wrote about this in a piece about Ariana Grande, about how the culture cannot set a floor for how thin is too thin because setting one would mean admitting the ideal itself is doing the damage. The finish line keeps moving.

Meanwhile, the public conversation has already moved on.

Coverage now focuses on what else GLP-1s might do: treat addiction, reduce inflammation, protect the heart, slow aging (Qeadan et al., 2025; Lincoff et al., 2023; Nature Biotechnology, 2025). Every new study is framed as another reason to expand access. The side effects are mentioned in the same paragraph and then set aside. The momentum is always toward the next application, never toward what it means to be relegating huge populations of people to a drug that our frameworks cannot sustain.

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None of this is an argument that GLP-1s should never be used. For people with diabetes or severe metabolic disease, these medications are clearly beneficial. It is an argument against treating lifelong exposure as the default endpoint of care. When a treatment’s success depends on never stopping it, asking who benefits from that arrangement is not cynicism. It is due diligence.

Medicine does not usually declare forever this early in the story. We do not yet have decades of safety data at obesity doses. We do not know what happens to people who take these drugs for 10, 20, or 30 years. What we do know is that the system pushing toward permanence is also the system that will drop people the moment costs become untenable.

“Just take it forever” assumes the drug will be available, affordable, and safe for the rest of your life. None of those conditions are guaranteed. And the people making the decisions where those guarantees would need to be enforced are not the ones whose bodies will pay the price when that promise falls through.

References

Aronne, L. J., et al. (2024). Continued treatment versus withdrawal of tirzepatide for maintenance of weight reduction. Journal of the American Medical Association.

The Banner. (2026). Howard County schools spent $8M on GLP-1 weight-loss drugs then pulled the plug.

Borchers, S., & Skibicka, K. P. (2024). GLP-1 and its analogs: Does sex matter? Endocrinology, 166(2). https://doi.org/10.1210/endocr/bqae165

Brookshire, B. (2026). The next wave of GLP-1 drugs. Scientific American.

Budini, B., Luo, S., Tam, M., Stead, I., Lee, A., Akrami, A., Vidal-Puig, A., & Park, A. (2025). Trajectory of weight regain after cessation of GLP-1 receptor agonists: A systematic review and nonlinear meta-regression. medRxiv. https://doi.org/10.1101/2025.06.09.25328726

EndoText. (2024). Definition, classification, and epidemiology of obesity. MDText.com, Inc.

Gasoyan, H., et al. (2024). Real-world weight loss outcomes with GLP-1 receptor agonists.

Grand View Research. (2024). GLP-1 receptor agonist market size and forecast.

Harvard Health Publishing. (2025). A popular alternative to a traditional sleeping pill. Harvard Health.

He, L., Wang, J., Ping, F., Yang, N., Huang, J., Li, Y., Xu, L., Li, W., & Zhang, H. (2022). Association of glucagon-like peptide-1 receptor agonist use with risk of gallbladder and biliary diseases: A systematic review and meta-analysis of randomized clinical trials. JAMA Internal Medicine, 182(5), 513-519.

Kerlikowsky, F., et al. (2025). GLP-1 receptor agonists good for body weight, bad for micronutrient status? Current Developments in Nutrition, 9, 107587.

Lincoff, A. M., Brown-Frandsen, K., Colhoun, H. M., & the SELECT Trial Investigators. (2023). Semaglutide and cardiovascular outcomes in obesity without diabetes. New England Journal of Medicine, 389(24), 2221-2232.

Lupkin, S. (2026). Spotty insurance coverage for GLP-1 drugs gets worse. WVIA.

Nature Biotechnology. (2025). Are GLP-1s the first longevity drugs? Nature Biotechnology, 43, 1741-1742.

Oliver, J. (2025). GLP-1 receptor agonists: Effective weight loss, limited metabolic restoration.

Qeadan, F., McCunn, A., & Tingey, B. (2025). The association between glucose-dependent insulinotropic polypeptide and/or glucagon-like peptide-1 receptor agonist prescriptions and substance-related outcomes in patients with opioid and alcohol use disorders: A real-world data analysis. Addiction, 120(2), 236-250.

Richards, J. R., & Khalsa, S. S. (2024). Highway to the danger zone? A cautionary account that GLP-1 receptor agonists may be too effective for unmonitored weight loss. Obesity Reviews, 25(5).

Rodriguez, P. J., et al. (2025). Discontinuation and reinitiation of dual-labeled GLP-1 receptor agonists among US adults with overweight or obesity. JAMA Network Open, 8(1).

Rubino, D., et al. (2021). Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance. Journal of the American Medical Association, 325(14), 1414-1425.

Ryan, D. H., et al. (2024). Long-term weight loss effects of semaglutide in obesity without diabetes in the SELECT trial. Nature Medicine, 30(7), 2049-2057.

WHO. (2023). Obesity and overweight.

Wolszczak, M., Wołodkiewicz, H., & Szmit, J. (2025). The impact of GLP-1 receptor agonists on women’s reproductive health: A review. Journal of Education and Sport, 12(2). https://doi.org/10.12775/jehs.2025.82.60194

At first, I bristled. It sounded like the kind of thing people say when they want to flatten a structural problem into universal personal failing, an “all lives matter” for body politics. But she was not wrong, and the more I sat with it, the more I realized that was exactly the point I needed to make.

We are all judging one another all of the time.

But that judgment is not evenly distributed, and it is not a random allocation of meanness that we all just happen to direct at each other. There is a specific engine driving the cruelty within our society we are seeing right now, and I am proposing that that engine is fatphobia.

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No one is born hating their body. Children do not emerge from infancy with an internalized understanding that their stomach should be flat, that their thighs should not touch, that their worth is tied to their circumference. They learn it, absorbing it from a culture that has spent centuries constructing fatness as a moral and aesthetic failure, and they learn it young.

By the same logic, no one is born knowing how to be cruel. They learn that too, from watching what happens to people who are fat, from absorbing the message that certain bodies are punishable, and from discovering that the safest position in a hierarchy is the one where you are holding the whip, not receiving it.

These two lessons are the same lesson, taught in the same classroom.

A participant in a study on internalized fat hatred explained it with devastating precision: “I find myself feeling superior to people who are fatter than me because I am in closer proximity to thinness than they are. Additionally, it has filled me with shame and self-hatred” (Rinaldi et al., 2019). The superiority is just the shame facing outward, and the two cannot exist apart.

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The self-hatred this culture produces in every single person is staggering, not a quiet background dislike but a violent, daily, structured hatred of your own body that the culture insists you carry and gives you nowhere to put down. You cannot resolve it or make peace with it. The only relief the culture offers is the chance to point it at someone else, and that is not a failure of character, but a design feature. The pressure has to go somewhere, and the hierarchy always tells you where.

And this is where the pipeline begins, and it works like pressure. Step one: you learn that fatness is the worst thing a person can be. Step two: you learn that you might be fat or become fat or be perceived as fat, and that knowledge fills you with shame and fear. Step three: the shame needs an outlet, and it cannot sit inside you unexpressed because it was never designed to.

Shame is not a static state; it is an active force that demands to be projected outward. Research on the Compass of Shame identifies the “attack-other” script as one of the primary strategies people use to manage shame, a pattern where individuals externalize their own shame by directing hostility toward others (Asgarizadeh et al., 2023). The cruelty does not originate in the attacker. It originates in the shame they cannot hold in.

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So where does the shame go? It goes to the safest possible target. And in a fatphobic culture, the safest possible target is always the person who is fatter than you, or the person who is visibly failing to perform the rituals of self-hatred, or the person whose body marks them as outside the hierarchy entirely.

This is where the “hurt people hurt people” pattern meets the specific machinery of weight stigma. The person leaving a comment on Alicia McCarvell’s TikTok telling her that her husband must be gay, that “bro deserved better” (I wrote about this in “If Shaming Worked, There Would Be No Fat People “) is not acting out of random cruelty but out of their own terror. They are looking at a fat woman who is visibly loved, visibly happy, visibly refusing to hate herself, and they cannot reconcile it with the story they have been told about what fatness means. Her refusal to comply with shame is a threat to the entire system they have built their survival on.

The hierarchy is held together by fear. Farrell (2011) describes fatness as a crucial marker in an economic hierarchy that deems thin bodies as civilized while it links fat bodies to adjectives reserved for those who constitute the dregs of society: primitive, degenerate, dependent, and uncivilized. The threat is not just being fat but being perceived as LIKE a fat person -- being seen as lazy, undisciplined, morally loose, someone who has given up and is therefore unworthy of respect or dignity.

This is why people still participate so eagerly in the shaming of fat people. It is a distancing strategy. Every time you mock a fat person’s body, you are saying to the audience: I am not that. I am on the right side of the line. Please do not put me on the other side. This is the same impulse that drives people to engage in “fat talk” (Alperin et al., 2014), that ritualizes self-deprecation about their own bodies that serves as a public performance of allegiance to thinness. They are buying safety with every fat joke.

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It is also what drives people to participate in public celebrations of weight loss, the liking and sharing and congratulating of transformation photos, because every single one of those interactions is a signal. You are saying: I recognize thinness as an achievement. I am on the side of the hierarchy that rewards it. The cruelty is quieter here, but the mechanism is exactly the same.

Which is a perfect segue to the compliance side, which is the part I think we do not talk about enough.

People align with societal cruelty not because they are sociopaths but because it helps them to be accepted in a fatphobic society. Participating in the shaming of fat people is a bid for acceptance, a way of saying: I know the rules, I am following them!

When you are already full of shame about your own body, pointing that shame at someone else is the only relief the culture lets you have, and it rewards you for it by letting you feel superior, righteous, like the one delivering the message instead of the one receiving it. You aren’t holding the whip, you ARE the whip! Wang and Sang (2020) found that the very self-regulation strategy that people use to manage their own body shame actually strengthens their explicit aggressiveness toward others.

But shame travels in two directions. Zhu et al. (2019) found that when other people are aware of an individual’s shame, that individual suppresses their anger and accepts unfair treatment rather than pushing back, meaning visible shame produces compliance rather than resistance. Together these findings show the full picture: shame either turns outward as aggression or inward as acceptance of cruelty, and the mechanism of self-control and the mechanism of cruelty are the same mechanism. You cannot train people to police their own bodies without also training them to police everyone else’s.

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The kapo analogy is one that also applies here; conditional proximity to power is one of the most reliable ways to secure participation in an oppressive system, where oppressed people are offered safety from the worst of it in exchange for enforcing it on others. That is what body hierarchies do, what racial hierarchies do, what incel ideology does, what “I’m not like other girls” does. Every single one of these is a promise that if you perform allegiance to the hierarchy, you get to be a little closer to the top and a little further from the bottom. The cruelty is the currency, and the compliance is the transaction.

And that policing extends far beyond the body alone. This is where the analysis has to account for the full scope of who receives our shame. Strings (2019) demonstrates that the fear of the Black body was integral to the creation of the slender aesthetic among fashionable white Americans. Fatphobia did not emerge in a vacuum; it emerged as a racial project, one that linked fatness to Blackness and Blackness to degeneracy and then demanded that both be disciplined. When we police non-compliant bodies, we are not just policing fat but policing the bodies that have been historically been marked as undisciplined and bad.

This is why fatphobia and racism cannot be untangled; they were designed together, and the same hierarchy that places thin white women at the top also places fat Black women at the bottom, with everyone else arranged somewhere in between, scrambling to prove they belong on the “right” side of the line.

Think about who gets the worst of society’s critiques. It is poor people, who are coded the way fat bodies are coded -- as lazy, undisciplined, excessive, a drain on resources. It is immigrants and ethnic minorities, whose bodies are read as foreign, uncontrolled, taking up space they do not deserve. The same logic, the same adjectives, the same disgust.

Fatphobia is the template, and it gets applied to anyone the hierarchy needs to put in its place.

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You can see this policing most clearly in internet comment sections, which are essentially an unregulated extralegal enforcement mechanism for the hierarchy. Every day, thousands of people take time out of their lives to tell strangers that their bodies, their cultures, their very existence is unacceptable, all through the templates fatphobia has instilled in them. The comments police all of them, and whether the specific insult targets a person's weight, their nationality, or their poverty, the language is the same.

They deliver it with the same confidence, the same relief of having somewhere to put their shame, the same assumption that they are delivering a message the target needs to hear, because they believe they are on the side of the dominant culture, that they are the ones upholding the standard, that their cruelty is a form of service. The fact that shaming does not work, that the research conclusively shows weight stigma drives people away from health behaviors rather than toward them, does not matter. The point of the comment was never to change the person on the receiving end. The point was to perform allegiance to the system.

Incel culture is one of the most obvious contemporary expressions of this hierarchy, and I think it is underanalyzed in exactly these terms. The defining grievance of incel culture is a perceived injustice in the distribution of romantic and sexual attention, and the people they blame are women, but the underlying logic is the same logic of the fatphobic hierarchy. Incel men are culturally coded as fat, as undesirable, as occupying the bottom rung of a hierarchy that values thinness, beauty, and social capital (Leger, 2024). They know they are at the bottom, and the rage this produces is not a rejection of the hierarchy but a demand to be let in. They do not want to dismantle the system that ranks people by desirability; they want higher placement within it. The cruelty they direct at women is the same cruelty the fatphobic hierarchy directs at fat people: an externalized shame response, a desperate performance of power from a position of perceived powerlessness. The targets are different, but the mechanism is the same.

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This is why I think we have to stop treating societal cruelty as an individual moral failing and start treating it as a structural output anchored in fatphobia. The cruelty is not random, and it is not just that we all judge each other and some people are meaner than others. The cruelty is produced by a system that requires people to hate their bodies and then gives them nowhere to put that hate except onto someone else. The system creates the shame, provides the outlets, and rewards the people who use them. It is a pipeline with a very clear design.

I think the political task here is not just to tell people to be kinder; kindness is not the intervention. The intervention is to dismantle the idea that some bodies are worth less than others and to refuse to participate in the hierarchy that requires cruelty to function. That means stopping the performance of allegiance, not laughing at the fat joke, not scrolling past the comment that calls a fat person disgusting, and being willing to be seen as close to fatness, as sympathetic to fatness, as on the side of fat people, even when the culture tells you that is social suicide. Because the only way to break the pipeline is to stop treating fatness as a fate worse than death. When you are no longer afraid of being thought of as fat, you no longer need to prove you are not, and when you stop needing to prove it, the cruelty loses its foundation.

References

Alperin, A., Hornsey, M. J., Hayward, L. E., Diedrichs, P. C., & Barlow, F. K. (2014). Applying the contact hypothesis to anti-fat attitudes: Contact with overweight people is related to how we interact with our bodies and those of others. Social Science & Medicine, 123, 37-44. https://doi.org/10.1016/j.socscimed.2014.10.045

Asgarizadeh, A., Ghanbari, S., Hosseinbor, M., & Pourmohseni Koluri, F. (2023). Development and validation of the Compass of Shame Scale (CoSS). Borderline Personality Disorder and Emotion Dysregulation, 10(1), 26. https://doi.org/10.1186/s40479-023-00231-2

Farrell, A. E. (2011). Fat shame: Stigma and the fat body in American culture. New York University Press.

Leger, E. C. (2024). “Misogyny is self defense”: A critical analysis of Incel discourse and belief on Incels.is [Master’s thesis, Carleton University].

Rinaldi, J., Rinaldi, C., & Douglass, M. (2019). Internalized fat hatred and the regulation of the fat body. In E. Cameron & C. Russell (Eds.), The fat pedagogy reader: Challenging weight-based oppression through critical education (pp. 71-84). Peter Lang.

Strings, S. (2019). Fearing the Black body: The racial origins of fat phobia. New York University Press.

Wang, X., & Sang, J. (2020). Self-blame curriculum, body shame, and aggression toward others. Studia Psychologica, 62(1), 3-15. https://doi.org/10.31577/sp.2020.01.791

Zhu, R., Xu, Z., Tang, H., Liu, J., Wang, H., An, Y., Mai, X., & Liu, C. (2019). The effect of shame on anger at others: Awareness of the emotion-causing events matters. Cognition and Emotion, 33(4), 696-714. https://doi.org/10.1080/02699931.2018.1489782

Even in the really little kids, the ones who have not had time to develop much of anything yet, you notice it. Some backs are wider. Some shoulders sit differently. Some kids are long and narrow, some are compact and dense. Some move through space like they own it, some fold into themselves. They are all healthy kids doing the same movements to the same music, and they all look completely different. This is what bodies are, before culture gets its hands on them: endlessly, irreducibly varied.

I grew up in a super fatphobic household, where my mother and my grandmother commented on people’s bodies constantly whether those bodies were young or old, always with some sort of moral judgment attached. One of the reasons I started researching body politics was to combat these residual voices in my head. I wondered, as I sat in the darkened theatre, whether other people were looking at these children’s bodies onstage and were making the same judgments my mother would have made. This child must be “good” and making good food choices. This child must not be. Not to mention what they might have been thinking about the irresponsibility of the fat kids’ parents.

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We have already decided, as a culture, that some of these children’s bodies are right and some are wrong. That somewhere between the preschool ballet class and the high school competition team, these kids will absorb the message that their particular configuration of bone and muscle and flesh is either acceptable or unacceptable.

Not based on whether it works (all of these dancing bodies clearly worked) but based on how closely it conforms to a universal ideal that does not actually exist. Imagine for a moment if every body really did look the same. The entire hierarchy would collapse. The sorting mechanism depends on visible difference to distribute worth, legitimacy, and care unevenly. The universal body is not just an impossible standard. It is a necessary fiction for a system that needs some bodies to count more than others.

The research on this is devastating and it starts absurdly early. Children as young as four label fatness as "bad" and express what researchers call anti-fat bias. By age six, kids are preoccupied with their bodies in ways similar to adults, and large numbers of them already experience body dissatisfaction (Greer, 2021). A study of eight to ten year olds found that the thinnest figures on a body image scale were the most nominated ideals and that no child nominated the two largest figures as ideal at all. The same study found that children perceived thin kids as best at sports, dancing, and mathematics, while fat kids were described as unintelligent, lazy, greedy, unpopular, and unable to play physical games. Thin children were seen as kind and happy. Fat children were seen as bullies (Chalker & O'Dea, 2009).

These lessons are not learned in a health class. This is the water children are swimming in. The messages from parents who pose them for pictures, from media that equates worth with thinness, from a culture that has decided that some bodies are good and some bodies are a problem before the person inside them has even learned to tie their shoes.

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Children do not arrive in the world believing that fat is bad. They learn it. They learn it early, often before they have words for it, and long before anyone introduces the language of health, discipline, or self-control. The lessons show up in children's media, where fatness is coded as villainous or foolish in ways so routine they barely register as meaningful. But they register. Children absorb the message before they can name it.

The logical endpoint of this education is the lunch shaming crisis that the Wall Street Journal reported on recently. Kids across the country are photographing their classmates while they eat and posting the images online, categorized as "the ugly mouthful" or "the lonely eater" (Jargon, 2026). A fourteen-year-old in Ohio stopped eating at school entirely after a photo of her mid-bite was posted to a class Snapchat page. "I know she's always had body issues," her friend told the Journal. A high school senior in San Diego estimates he has been targeted thirty to forty times and now eats alone in secluded spots on campus, afraid of being seen.

We have created a world in which children are afraid to eat. Not afraid of the food. Afraid of being seen eating it. Afraid that their hunger, their mouthful at a lunch table will be captured and broadcast as evidence that their body is wrong. I think about this in relation to what I wrote in “The Weight of Growing Up Fat.” In that piece, I wrote about the moment one of my twin boys started talking to me about being “squishy” like it was a bad thing. He was eight. He was already worrying about his body, already absorbing the message that his particular shape was something to be ashamed of. The message that a body needs to be fixed arrives before the child has any framework for understanding it. It simply lands.

We are the ones who teach this. We look at a child and see a future problem instead of a present body. And then we act surprised when those children turn around and do the same thing to each other. The mechanism is not mysterious. The intensity of this transmission, the emotional charge behind it, is not about health education or parental concern. It is about a system that invests fatness with moral meaning so that visible discipline can stand in for worth. Some bodies must function as warnings so that others can function as rewards. The judgments feel rational because they have been rationalized, generation after generation, but underneath them is something far less scientific: a deep cultural investment in the belief that the body tells the truth about who a person is.

Here is the thing: if it is obviously, visibly ridiculous to expect a room full of four to seventeen year olds to all look the same, if you can see with your own eyes that children are built differently and that this is not a problem, then it is equally ridiculous to expect it of adults. The universal body does not become more real just because we get older. The lie does not become true. We just get better at pretending it is.

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The universal body: the belief that there is one correct shape, one right way to be embodied, and that every deviation is a problem to be solved. The academic literature calls this the myth of control, the belief that it is possible, through sufficient effort, to have the bodies we want, and that failure to achieve the desired body is a moral failing (Abel, 2020). Susan Wendell (1996), who wrote about this, observed that “people embrace the myth of control in part because it promises escape from the rejected body.” The universal body is the body we are promised we can have if we just try hard enough, buy the right things, eat the right way, and discipline ourselves enough.

Why do we fight so hard against the idea of acceptable variability amongst our own bodies? When you look at the history, the emotional charge around fatness has never been primarily about evidence or health. It has been about meaning. We are not protecting a health metric. We are protecting a way of making sense of bodies that turns deeply moral judgments into something that can feel neutral and responsible.

I think about the attachment rupture, that idea that we learn to disconnect from ourselves, to treat our bodies like a project under constant renovation rather than a living thing that needs care. Care AND food. We are taught that our body is a problem to solve before our life can begin. That if we were thinner, smaller, prettier, more disciplined, more controlled, then maybe we would finally deserve ease. Maybe we would deserve love. Maybe we would deserve rest.

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But the universal body is a lie.

It does not exist. It never has. The bodies at the dance recital prove it, kids who have barely started living, already shaped differently, already not fitting the mold they may have not even been told about yet. And if we can see that the ideal was never real for children, we can see it was never real for anyone.

The real work is not fixing our bodies to match the myth. The real work is letting the myth go. Looking at a room full of children and seeing not the ones who might grow up to be too fat or too thin or too wide-shouldered or too narrow-hipped, but just children. Each one built exactly the way they are built. All of them normal. None of them wrong. All of them beautiful.

References

Abel, S. (2020). Let's talk about your weight: How fatphobia manifests in therapy [Doctoral dissertation].

Chalker, B., & O’Dea, J. A. (2009). Fat kids can’t do maths: Negative body weight stereotyping and associations with academic competence and participation in school activities among primary school children. The Open Education Journal, 2, 71-77.

Greer, J. E. (2021). The utilization of a theology of human embodiment to address body image [Doctoral dissertation].

Jargon, J. (2026, June 1). ‘Lunch shaming’ has made kids too terrified to eat at school. The Wall Street Journal.

Wendell, S. (1996). The rejected body: Feminist philosophical reflections on disability. Routledge.

“Fatness is unhealthy!” people say, and somehow that justifies the scrutiny, the mockery, the public commentary, the unsolicited advice, all of it is just concern. Care. Tough love dressed up as “responsibility.”

We do not apply this logic anywhere else. Nobody looks at someone fighting cancer and starts commenting on their body or questioning their choices. We do not scrutinize cancer patients’ bodies in the name of health, because we understand that would be cruel, not caring. The contradiction is right there: the body is only treated as public property when it is fat. The concern is not about health. “Health” is just the language that their cruelty learned to speak fluently.

Here is the thing though. None of us can actually tell how healthy or unhealthy a person is just by looking at them. Unless they are actively bleeding, you are guessing. And the guess is doing a lot of damage. (Stigma has measurable physiological consequences — I wrote about this in my post “If Shaming Worked, There Would Be No Fat People.”)

I watched this contradiction destroy a friendship during the pandemic.

“Tom” is a fat guy. We have known each other for years, and I love him dearly. During the early COVID vaccine rollout in his non-US country, eligibility was tiered by risk factors, and because of his weight, he qualified for the vaccine earlier than a lot of people our age. One of our mutual friends, a thin woman who was gym-obsessed (and a very serious alcoholic,) was furious.

When Tom got his vaccine appointment before her, she confronted him. It was not right, she said. He was so unhealthy that he did not deserve to be prioritized. She was healthy. She took care of herself. She went to the gym.

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The irony writes itself. A woman with a serious drinking problem, standing in front of a fat man, telling him her health was better than his. Thinness was the only metric that counted. The scale told her she was fine.

The scale does not test for alcohol use disorder.

Nobody was publicly concerned about her drinking. Thinness shields you from that kind of scrutiny. It creates a bubble of presumed wellness that even active alcoholism cannot puncture. But Tom, existing in a fat body, does not have that bubble. His health was up for debate.

She was not actually worried about his health. She was worried about what it meant that a fat person got something before a thin person did. It violated the hierarchy. The covenant of thin. And hierarchy is what health concern is often really protecting when you scrape off the language. (For more on thinness as a moral credential, see my post “You’re Not Better Than Anyone Just Because You’re Thin.”)

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The pandemic made this logic impossible to ignore because it stopped being interpersonal and became policy.

Early in the COVID-19 crisis, when hospitals were overwhelmed, the Italian Society of Anesthesia published clinical ethics recommendations stating that age, comorbidities, and functional status should be carefully evaluated, and that limited ICU resources should go to patients with the highest chance of therapeutic success (Vergano et al., 2020). The guidelines did not name weight specifically, but they did not have to. In a system that used comorbidities to determine who got care, fat patients were at a disadvantage because weight is already classified as a comorbidity within that system.

In the UK and the US, a BMI of 40 or higher was listed as an independent risk factor for severe COVID-19 by government health authorities. But here is where it gets slippery: no available data showed adverse COVID outcomes specifically at the cutoff of 40 or higher (Flint & Tahrani, 2020). The threshold was chosen without evidence that it meant anything clinically distinct. The same authors pointed out that this ambiguity cut both ways: it created anxiety for people above the cutoff who could not get a clear explanation for why, and it gave a false sense of safety to people lower BMIs, who might assume they were not at risk. The policy existed. The evidence for where the line was drawn did not.

This is the part that should worry everyone. The idea that “fat people are unhealthy” got baked into triage protocols at the height of a global health emergency with no actual evidence that it was a factor. A BMI number that had never been validated as a meaningful cutoff for COVID outcomes was used to sort people into risk categories. Those categories influenced who got access to ventilators. That is not concern.

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And it was never just COVID. The same dynamic plays out every time a doctor attributes a fat patient’s symptoms to their weight without examining them. (I’ll point you here towards the story about Rebecca Hiles). Every time someone looks at a fat body and assumes they know what is happening inside it. You cannot see cholesterol. You cannot see blood pressure. You cannot see inflammation or insulin resistance… OR liver function.

The assumption that fat means unhealthy was already embedded in medicine long before COVID. There is a whole body of research called the "obesity paradox": studies consistently showing that in chronic conditions like heart failure and cardiovascular disease, overweight and obese patients often have better survival outcomes than their "normal weight" counterparts (Lavie et al., 2015; Ortega et al., 2013). This does not mean fatness is protective. It means the relationship between weight and health is not the simple story we keep telling. The literature exists. It is peer-reviewed. It is decades old.

And yet the cultural assumption that fat bodies are sick bodies has not budged. Because the assumption was never really about the evidence. By the time COVID arrived, that assumption was already built into the protocols, the triage categories, the operating system of medicine. Fatness has become a foregone conclusion in the cycle of our healthcare system so before you claim that you’re only echoing the concerns of doctors, perhaps check the research first.

Because you can only see a body, and everything else is your projection.

You cannot weaponize health against people whose suffering you respect. This language only comes out when the target has already been marked as socially acceptable to shame. And fat people are the most marked group we have. The pandemic did not invent this logic, but it did expose it. In triage committees and in living rooms. In clinical guidelines and in the mouths of friends who thought thinness made them righteous.

Health concern is not real concern. It is a social permission slip to say the quiet part loud. And until we stop pretending that calling someone unhealthy is the same as caring about them, the hierarchy stays intact, and the people whose thinness buys them immunity keep being treated like they earned it.

References

Flint, S. W., & Tahrani, A. A. (2020). COVID-19 and obesity: Lack of clarity, guidance, and implications for care. The Lancet Diabetes & Endocrinology, 8(6), 474–475.

Lavie, C. J., De Schutter, A., & Milani, R. V. (2015). Healthy obese versus unhealthy lean: the obesity paradox. Nature Reviews Endocrinology, 11(1), 55–62.

Ortega, F. B., Lee, D. C., Katzmarzyk, P. T., Ruiz, J. R., Sui, X., Church, T. S., & Blair, S. N. (2013). The intriguing metabolically healthy but obese phenotype: cardiovascular prognosis and role of fitness. European Heart Journal, 34(5), 389–397.

Vergano, M., Bertolini, G., Giannini, A., Gristina, G. R., Livigni, S., Mistraletti, G., Riccioni, L., & Petrini, F. (2020). Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: The Italian perspective during the COVID-19 epidemic. Critical Care, 24(1), 165.