The Fat Doctor Podcast

Your Health Is Not Determined by Your Size

• Dr Asher Larmie • Season 5 • Episode 24

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 Health and weight are two completely separate things that we've been taught to view as synonymous. While society insists that being fat is inherently unhealthy, the evidence tells a different story. In this episode, I break down why genetics, not lifestyle choices, primarily determine our weight, how weight stigma actually causes poor health outcomes, and why fat people often have better medical outcomes than thin people. I challenge the fundamental assumption that body size equals health status and explain why perpetuating this myth isn't just wrong—it's literally killing people. 

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Hi, everyone. Welcome to episode 24 of season 5 of the Fat Doctor Podcast. I'm your host, Dr. Asher Larmie. You're back last week didn't put you off. That's exciting. One of the things I'm getting in the habit of doing is recording a month's worth of podcasts in a day. So whilst it has been a week for you, it's actually only been 5 minutes for me. So yeah, getting my brain into gear, talking to you today about something that you probably already know.
And you might be like, oh, we already know this, Asher. I remember once being told by somebody I'm sick and tired of having to listen to the same old, same old, like some of us are moving on from breast milk. We need the meat.
I blocked that person from my life because I was like, oh, fuck off!
Not everybody is in the same place. Some people might be tuning in for the first time, listening to something they've never heard before, and thinking this is a revelation, and some of you might be like, oh, my God! I've heard this a million times. I'm sick of it. Well, what can I say? For those of you who are new to this information, welcome. For those of you who are bored, skip. It's no problem. Don't get upset if you choose to skip this one. And basically, this episode is all about the fact that our health is not determined by our size. In other words, our size, our weight, and our health, whatever you want to call that, are 2 completely, entirely separate things, and whilst there are some associations, possibly between the 2, those are really not very convincing, for want of a better word. Associations that are very easy to dispute, very easy to just kind of pick holes in those theories.
So I would like to argue that there's health, whatever that means. And if we're getting into it and talking about what does health mean, we have to go right back to the beginning of this season when I talked about how health is pretty much impossible to define, and we've been talking about ever since how our idea of what health is. But even if you want to be very specific, like heart health or metabolic health, we put that in one hand. Yeah, that's health. And in the other hand, we have size, weight, BMI, whatever you want to call it. And those 2 are very separate things, very separate, 2 entirely separate entities.
We've got to stop talking about them as if they're the same, as if one is the same thing as the other, as if we can substitute one for the other. And that's what we do. Oftentimes, when we're talking about health, we'll substitute weight in there or size in there, like the 2 mean the same thing, and they do not.
So I'm just going to spend the next 20 minutes or so telling you unequivocally why I am absolutely confident that one has nothing to do with the other, and I haven't even bothered to write notes this time, so confident am I about this. I didn't even bother to write notes, because I've said this over and over and over again, and I will keep saying it. Your health and your size are 2 completely different things. Health is not determined by size, size is not determined by health. There are lots of factors that influence our weight.
At the top of the list is genetics. I was talking to my daughter the other day because she was really concerned that she is stopping growing. She's not going to be very tall. She's worried that she'll be short. She's like, what if I'm short then?
I'm like I'm 5 foot 2. My mother was 5 foot 2. Her mother was 5 foot 2. Her mother was 5 foot 2, and I was like, even if you look at the women in your dad's side of the family, they're not very tall. You do not come from a family of tall women, tall men, yes, tall women, not so much. And apologies for being very binary about it. My daughter's 12. That's how I explained it to her. But even as I'm talking about it, I'm like, oh, that was very binary of me, anyway. The point I was trying to make for her was that maybe you will be short. She did not like that. She needed me to tell her that she was going to keep growing, and she was going to get taller, and I was like, no, I stopped growing around 13. I've been 5 foot 2 since I was around your age, so you might stop growing. And that's not what she wanted to hear. But I was like dude, it's genetic. There's nothing we can do about it like it's done.
It is determined by your genetics, your height, and you may not like it. You may want to be tall, I get it. Short people, shortness is associated with all sorts of things. Taller is better, taller is easier, and I know this because every day when I'm cooking, and I mean literally every day when I'm cooking and I'm seasoning my food, which, of course I do. I season my food with a lot of different spices. They're in a cabinet that's right up here. And I have to reach on my tiptoes to grab every garlic powder. It drives me freaking crazy, the garlic powder, and the paprika, and every time my husband says, why don't you move it down a shelf? And I'm like because the other shelf is already full of other stuff that I need, and I'm frustrated. I'm frustrated because I don't like being 5 foot 2. I would like to be a little bit taller, so that I can reach the things in my kitchen. But I can't. I can't. And that is the way it is, that is the way of the world, and I've accepted that. But I get it. My daughter doesn't want to be 5 foot 2. She wants to be at least 5 foot 7. And I'm like, I don't know what to tell you.
Genetics are genetics, but that is really important to understand that genetics are genetics. And just as your height is determined by your genetics, predetermined from when you were a baby and before at conception, so, too, is your weight. About the same number of genes, maybe even more, your weight is predetermined to a point.
Now, there is this really interesting field of genetics, which is called epigenetics. The idea that genes, basically, for want of a better word, get turned on and turned off depending on your environment. We've always known about nature versus nurture. We've always known about environment and genetics and the interplay between the 2. So I'm not saying it's just genetics. There's definitely an environmental component, too. There's even an intergenerational component in which your genetics are not just determined by your chromosomes and your parents and who passes on what through which gamete, but also that the epigenetics, this sort of turning on and turning off of genes, can be passed down through generations as well. Fascinating stuff, fascinating. We don't know enough about it to really have more than theories at this stage, but we know genetics plays a huge role.
And as I said, environment and this is horrible word which I'm going to use now, it's vile obesogenic environment, this fucking word that gets tossed around all day long. And what a fucking disgusting way to describe it! But we're told oh, we're very sedentary nowadays, like, you know, we don't move as much, and we sit down. Yeah, no shit we are. You know whose fault that is? Capitalism. The industrial revolution, like there's loads of people we can blame for that. It's not our fault. It's not our fault that in order to earn enough money to just about pay for eggs, even though eggs still cost a fortune, in spite of all the promises out there, to just about be able to afford the basic necessities. Most of us are having to sit down for several hours in a day to work in a job. That's not our fault, that's society's fault. But yeah, I would agree that our environment has changed over the last 100, 200 years. Our environment has changed, and that's no doubt had an impact on our genetics. But that's not, that's a universal thing that has changed for all of us.
And of course it's changed for all of us, but not all of us have gotten fat, right? Thin people are not more active than fat people, that's bullshit. There is no evidence to support that whatsoever. Thin people are not more active than fat people. I'm not talking about thin fluencers. I'm not talking about people on Instagram who spend a lot of time. Although, oh, my gosh! I watched this video. Forgive me for getting sidetracked. But I watched this video of this guy who worked in props. And he had all of these like fake weights. And he was like they have some weight in them, so that when you're lifting them it's not like you're lifting sort of paper, but they're nowhere near as heavy as they appear. And he was like loads of influencers, they look like they're lifting fifties, but they're actually only lifting 15, and they just do it to look good. And I was like all of it's fake man. It's so fucking fake. But even those dudes, even the ones who really are lifting, lifting good for you, I mean, that's great. That's your thing. I get it. But you represent 0.001% of the population. The vast majority of people are not doing that and do not get to dedicate their entire lives to exercise because they have to work to earn a living. They don't have the privilege, if you will, to mess about on Instagram recording videos of them in the gym. So yeah, those people, most people in real life are doing sedentary jobs nowadays. And so, of course, some of them are fatter, and some of them are not. So we can't blame the environment because it's impacting all of us universally.
And I know thin people want to pretend that they are more virtuous than fat people, but they're not. They're just lying about it. They are eating the same food and drinking the same thing. That's not to say that there aren't people out there again who are very conscious about what they're eating. But they're a very small percentage of the population, right? Like just the people that you meet on a day to day basis. They're also working 10 hours a day sitting. I mean, I refuse to believe that they're all super active in their jobs. They've somehow found a way around capitalism because they haven't.
So yeah, there's environment. But the environment doesn't tell the whole story. Genetics doesn't tell the whole story. There are all sorts of other things, so some of us are more sensitive to insulin, for example, are more insulin resistant. Some of us make a lot of testosterone. Some of us who have ovaries are making a lot of testosterone, and as a result are gaining weight. Some of us have thyroids that aren't doing a good enough job, some of us are taking medications that make us gain weight. There's all sorts of medical reasons why people gain weight. And then there's dieting.
And dieting is without doubt the single biggest, largest risk factor for weight gain, for want of a better word. Like, if you want to guarantee weight gain, the best way to go about that is to go on a diet. The best way to do it is to starve yourself. Starve yourself for a bit, and in the long term chances are you're going to gain some weight.
And those of us who have been starving ourselves in one way or another for decades, have been gaining weight, I would say slowly, but not necessarily, sometimes quite rapidly, gaining weight over the course of our lives, because every time you go on a diet your metabolism changes, the way you store fat changes, genes get switched on, genes get switched off, your gut, the way your gut works changes, the function of your gut changes, your brain chemistry changes, all sorts of things change when you go on a diet, and some of that lasts forever, and some of that lasts for years. Some of that lasts until the next diet. But either way we're messing with all sorts of very important biofeedback mechanisms in our body, and we only recently started doing that. We've only recently started starving ourselves intentionally as a species. We have been starved forever, you know, throughout time famine has been, and always will be. Well, I don't want to say always will be, but famine, historically, has been a part of the human experience.
So it's not like we've never starved before. Of course we have, but not intentionally. We haven't been intentionally starving ourselves until the last 100, 150 years. That's a weird thing to do. There is no other animal out there, a mammal out there or animal, certainly no mammal out there that intentionally starves itself. That's just weird. It's not what we're supposed to do. Our body is a bit like what the fuck is going on here. Our body can't tell the difference between intentional starvation and just starvation. As far as our body is concerned, every time we do not put enough energy into our bodies, and we're consuming less energy than we're expanding, than when we're using, as far as our bodies are concerned, that is starvation.
And it's bad for us. A day is not a problem, a couple of days, not a problem, a week, maybe our body's like, okay, we can handle this. But weeks, months? No, our body's like, no, no, absolutely not because we're very, very stressed and does all sorts of things. Now, I've talked about this in great detail. I even have a, if you're interested in finding out about the science behind this, I have a course on my learning platform. It's called Unshrinkable, and it just basically tells you all the different ways in which you're unshrinkable using science to explain. So yeah, our bodies don't shrink, they just grow, and the more we starve them the more we grow.
So that's a brief overview of how our weight is controlled by a number of factors, almost all of which are out of our control. And really the only thing that is within our control, the main thing that's within our control is dieting. So if you want to control your weight in any way, which, as I said, it's not that easy to do. But if you want to control it, the only real measure of control is to not go on a diet. That's the best thing that you could possibly do. If you say to me, actually, what's the best way to avoid gaining weight in the future, I will say to you, don't diet. Everything else is not under your control, but don't diet, because that's how you gain weight.
That actually wasn't what the whole purpose of this podcast was about. It wasn't just about why we get fat or what controls our weight, I should say, but it's that weight and health are not synonymous with each other. They are not linked to each other. One does not cause the other. We are absolutely adamant that being fat is bad for your health, and that is absolutely not true.
Now, caveat, here being fat means you get treated badly, being fat means less opportunities for employment, less opportunities to move around in the world. Social isolation, socio-political and economic, yeah, you are more socially isolated, worse financial opportunities, fewer financial opportunities. So you'll probably be in a lower socioeconomic group, even if you are somebody, say, like myself, with a medical degree, you're still earning less money than your colleagues. That's statistically the case, and it's harder to travel, and it's harder to find clothes, and it's harder to go out and to socialize and to mix with other people, and to go to restaurants and to get on a fucking bus, all of these things are just much harder. The fatter you are, the harder it gets. So yeah, being fat means you get treated badly in the world. It also means poorer access to health care. It means that your doctors will not care about you. It means your doctors will spend less time examining you, less time investigating you, looking for the cause of your symptoms. They'll just blame it on your weight. They'll spend less time treating you. They'll spend less time talking to you and educating you, and quite frankly, as is often the case, your doctors just won't like you, and they won't care about you, they just won't care, and if they don't care, then they're less inclined to do anything to help you. And so there are real tangible consequences to being fat in the world today, and as a result that will impact our health.
Because if you don't have as much money, and you're more socially isolated, and you have poorer health care, etc. etc. That will absolutely impact your heart health, and your metabolic health and your mental health and your emotional health and your experience of pain, and it will increase your chances of having depression and anxiety, and it will cause chronic stress and chronic stress causes chronic inflammation and chronic inflammation is associated with all sorts of health conditions. So there are a number of ways that being fat in today's society absolutely impacts your health.
But it's not the fat. It's the society, right? And that's the key here.
Everyone is going to try and persuade you that the reason that fat people are more likely to have heart disease is because they're fat. That's actually not true. The reason fat people are more likely to have heart disease is because society treats them like shit, and therefore they have more chronic inflammation and poor access to healthcare and doctors who are less willing to investigate them, and blah blah blah, and so on and so forth. So yeah, they are right, but they are also wrong. So health is determined by size, but also it isn't. Health is determined by size, because society hates fat people, not because being fat impacts your health. In fact, it's really fascinating.
Let me get into it. Did you know that if you go into ICU with sepsis, you're septic, you've developed an infection, right? Anyone can develop an infection, that can happen to anyone. So septic, you go into ICU. The fatter you are, the better the outcomes. You are far more likely to leave the ICU and go home if you're fat, and the fatter the better.
There's all sorts of theories about this. They call it the obesity paradox. It's not a paradox. There's all sorts of reasons why being fat is really good for you. Being fat protects you when you fall. That's why fat people are less likely to die of hip fractures when they're older. That's why fat people are less likely to be frail when they're older.
Being fat helps to maintain your blood pressure. So when you're in a situation where your blood pressure is being threatened, for example, you're in ICU, fat people are able to maintain their blood pressure, renin angiotensin system. All sorts of reasons. I won't go into it.
Fat people have a store of nutrition. It's not an unending store of nutrition. That doesn't mean that we can starve ourselves because we've got all the nutrition in the world. It doesn't. But it does mean that when we end up in hospital we do better. That's why we fare better in terms of surgical outcomes. People are always saying, fat people have poorer surgical outcomes. Really interesting when you look into it, you're like, not so much, actually.
In some respects, yes, there are certain surgical outcomes that are worse in fat people. Like, for example, blood clots, definitely higher risk of blood clots in fat people. But then that might have something to do with the fact that one of the best ways to avoid a blood clot is to move as quickly as you can post surgery, and sometimes people need help moving, and when they're fat they don't get the help because nurses don't want to move them, because it's a lot more effort. And so they stay in bed for longer and so higher risk of blood clot. That's possibly true. I'll give you that. But when it comes to all complications, that's not always the case.
For example, fat people, much less likely to need a blood transfusion after an operation, significantly less likely to need one. That's helpful, isn't it?
Fat people actually fare quite well when it comes to ICU, when it comes to if your heart's not doing so well, your kidney's not doing so well, if you've had a heart attack or a stroke, then it's definitely better to be fat, definitely. No question.
And we know, actually, we know this. Healthcare professionals can tell you. If you see somebody who's in chronic kidney failure and they're fat, you're like, okay, they're just going to live longer. We know this for a fact. That's just the reality of it.
Fat people, older, fat people, they are much more robust, far less likely to fall, break things and die.
So the idea that being fat is inherently bad for your health, that is not true, and that is backed up by science, and it's called the obesity paradox. But it's not a paradox. There's nothing paradoxical about the fact that actually being fat has many benefits. It's why, once upon a time in society being fat was associated with being wealthy, because people who are fat are getting enough nutrition, and getting enough nutrition is really good for you.
Now, less of an issue nowadays in 21st century, where not everybody who is fat is getting enough nutrition. In fact, a lot of people who are fat are not eating enough, and a lot of people who are fat are, even though they may live in parts of the world where they should have access to good quality nutritional food, they don't, because, as I said, if you're fat, you're less likely to have money, and if you don't have money, then you can't afford good quality nutritious food. So there's that.
But in general, being fat has many benefits, proven benefits, proven without a shadow of a doubt benefits, and all of the quote unquote risks that are associated with being fat could absolutely be explained by weight stigma.
Like, if you say people who are fat are more likely to have high blood pressure, I could argue, yes, people who are fat are more likely to be discriminated against, to be stigmatized, to receive poorer health care, and to have more stress. And that puts up your blood pressure.
Being fat is associated with diabetes. Yes, that's true. But people who have type 2 diabetes almost certainly have insulin resistance. Insulin resistance causes weight gain. Therefore, people who are insulin resistant are more likely to be fat. Therefore fat people are more likely to be diabetic. See, it's just logic, isn't it?
Fat people don't do as well when they're admitted into the hospital. Yes, that's true. Doctors and nurses treat fat people terribly, so of course they don't do as well when they're admitted into hospital because doctors and nurses have really shitty attitudes towards fat people. I could go on and on and on and on. I told you last time that there's a book out there called Jenny Needs a Knee, But She's Too Fat to Get One, and the reason why fat people around the world are being denied access to surgery is because it's quote, unquote, not safe for fat people. And this is unequivocally false. There is no question that knee replacement surgery is as safe for fat people as it is for thin people, more or less.
Possibly maybe potentially being fat increases your risk in some areas, possibly, but not definitely, because there's one meta analysis I looked at. There were 18, I think I've talked about this before. There were 18 studies, 9 of which found that there was an increased risk for being fat, and the others found there wasn't an increased risk of being fat, so, you know, still, the jury's out. Nevertheless, even if there is an increased risk, the increased risk is so small that it's irrelevant. Really, it's irrelevant.
People who are fat do just as well after having a knee replacement, and, best of all, people who are fat tend to have worse baseline pain scores because they're more likely to be neglected for longer periods of time. So when it comes to baseline pain scores, people who are fat have worse pain, and therefore, by the time they've had their replacement, their joint replacement, they actually fare much better. Their pain scores go from really quite bad to small, low pain scores, whereas thin people have less pain to start with, so the improvement isn't as dramatic. So one could argue actually, fat people do better after a joint replacement in terms of pain scores, they do exactly the same in terms of function.
So I've kind of lost my train of thought a little bit, but I hope we understand that health is not the same as size, that we cannot swap one with the other. Oh, health! Oh, size, it's not the same thing. You cannot look at a person and go, you're fat, therefore you're unhealthy. We can't look at a thin person and go, you're thin, therefore you're healthy. In fact, when it comes down to it, when we're looking at cardiac health, and we're looking at blood pressure, cholesterol, HbA1c, etc. etc. When we look at BMI categories, we find that a third of people with a supposedly unhealthy BMI, because they're fat, actually have very normal blood pressure, HbA1c and cholesterol. Not that that's something to brag about. By the way, congratulations, you doesn't mean anything. I'm just pointing out the BMI is useless. But here's the kicker, a third of people with a quote unquote normal BMI have abnormal blood pressure, cholesterol, and HbA1c.
So my point is, you cannot assume that a fat person is unhealthy. But, more importantly, you cannot assume that a thin person is healthy. You cannot assume that a person's body size somehow says something about their health, because it doesn't. And I'm just talking about cardiac health here. I'm just talking about 3 markers of cardiac health. That's not even cardiac health. That's just like potential markers of cardiac health: blood pressure, cholesterol, and HbA1c, which we're all obsessed with. But even when it comes to those, there's no, this idea that being fat, somehow, no sorry, wrong.
This is really important, because physical health, mental health, any kind of health cannot be measured by the size of someone's body. And therefore, when we assume that a fatter person is less healthy, not only are we wrong, which is problematic in of itself, but we are perpetuating stigma.
These beliefs and judgments and stereotypes exist in society because we allow them to exist in society, because every single one of us, most of us holds these beliefs and perpetuates this stigma by looking at a person, treating them differently, making assumptions about them, talking about them, writing about them. The amount of times I've read an article in a paper that I would call a reputable, possibly even liberal newspaper, I'll read it and just be like, are you fucking kidding me? They just talk about fat and health like they're synonymous. They just make the assumption fat is unhealthy like that's canon. We don't have to, but that's like saying the earth is round and gravity exists. Fat people are unhealthy, the end. That's not true. How many studies have I read that begin like literally, the introduction is essentially being fat is really bad for your health, without any supporting evidence, and when they do reference it, it's just some bullshit reference that, there's never any kind of thought going into this. We just make that assumption, it's one that exists already, and those of us who are like well, that's not actually true are having to push back against a giant wall of assumption, of stigma. And so not only are we wrong, but we are perpetuating, we're making it worse. We are allowing it to exist. We are not actually going, oh, hang on a second. Can we stop making that assumption and actually be a bit more objective about this, and actually think about it.
And the reason that's important is because weight stigma is an independent risk factor for poor health outcomes. So it's not just that we're wrong. It's not just that we're stigmatizing people and perpetuating that stigma by allowing it to continue to exist in society and by not challenging it. But weight stigma actually causes poor health outcomes.
So if we continue to assume that being fat is the same as being unhealthy, and we continue to tell other people that being fat is the same as being unhealthy, then we are harming people, we are hurting them. I would even argue that we are killing them. Poor health outcomes can sometimes mean death.
The very act of stigmatizing people for their weight harms health and then creates a self-fulfilling prophecy. And I get it that works out in your favor, right? Those of you perpetuating the stigma. It works in your favor, because then you can be like, see, ta-da. Here's proof.
And I'm aware that people listening to this podcast probably do care. And the people that need to listen to this podcast will never listen to this podcast. But if people, especially if you're a healthcare professional and you claim to care. If you claim to care, then it's your responsibility to challenge this stigma.
It's your responsibility to stop assuming that fat people are unhealthy. It's your responsibility to challenge the negative assumptions and beliefs and stereotypes that exist. It is your responsibility to say, hey, I'm going to look beyond your size and treat you as a human being. That's your responsibility.
And sometimes I just think I'm talking to a brick wall. Because why would anyone care? But that doesn't matter, right. I'll just keep saying it. Your health is not determined by your size. There's plenty of evidence to support me. I am not cherry picking the evidence.
Thanks for listening, and I will see you or hear you. No, you will hear me. I'll not hear you. You will hear me or hear from me in the next episode. I don't know if you know this, but you can leave me a message through my podcast. I've turned this thing on now. So if you want to send me a message through my podcast, you just go to my podcast, and you click on it. And then, yeah, you can give me some feedback, ask me some questions. Do whatever you want. I'd love to hear from you. I love hearing from you. Otherwise, come back. Join me next week.