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Jennifer: This is Jennifer from South Orange, New Jersey. As a fat woman, I have been nothing but weight-shamed by the medical community for my entire life. It began at adolescence and it never stopped. It interferes with everything. People don't believe you when you complain about things, where you're told that all of your troubles will be solved with weight loss.

Anthony: Hello, I'm Anthony. I'm from Cleveland, Ohio. I feel that the medical establishment at large shames many people from the African-American community in particular, by continually using an example of institutional racism, a marker of health known as the BMI.

Jennifer: The BMI is an artificial and outmoded way of assessing health.

Anthony: Once you trace the origins of its use, you will see what I am talking about.

Rebeca Ibarra: Hey, everyone, I'm Rebeca Ibarra, in for Tanzina, you're listening to The Takeaway. Since the start of the pandemic, jokes and memes about gaining weight have been everywhere on social media, everything from the "Quarantine 15" is the new "Freshman 15" to insensitive before and after caricatures, and now fatphobia is making its way into the vaccination debate as people who qualify for the COVID-19 vaccine because of their body mass index, or BMI, are being shamed or scrutinized for getting priority.

Fatphobia and fat stigma are far from new, they've long been widely acceptable within the medical establishment and in society at large. For more on this, we're joined by Virginia Sole-Smith, Journalist, and Author of The Eating Instinct. She's been covering COVID and weight stigma for the Medium publication Elemental. Virginia, Welcome to the show.

Virginia Sole-Smith: Thank you for having me.

Rebeca Ibarra: To start, can you tell us what the difference is between fatphobia, fat-shaming, and weight stigma? Are these largely interchangeable terms or are there important differences?

Virginia Sole-Smith: They are somewhat interchangeable. Weight stigma is the term that we see in research. It refers to the set of negative beliefs and stereotypes and bias that crop up when a doctor sees a person in a higher body size, for example, and immediately assumes that this is someone who doesn't exercise, who needs a weight loss intervention. The term fat-shaming tends to be more of a personal thing, maybe that's how your friends talk when you're eating, or the jokes, the memes that you just referenced.

Fatphobia is a term used by activists who are really trying to reclaim the concept of fat for important reasons. What they're saying there is, all of this bias and negativity that we're encountering, it's not based on science, it's not based on facts about larger bodies. It's based on a phobia, on a form of stigma. This is similar to homophobia or racism. This is a form of oppression.

Rebeca Ibarra: Can you remind us about the public health messaging around COVID and weight early on in the pandemic? What were we hearing?

Virginia Sole-Smith: Pretty early on, I think April was when the first study came out, we started to see research where they were looking often at one hospital or one country's data set and trying to figure out who were the people most impacted by severe courses of COVID, who were most likely to end up on ventilators, higher mortality rates. They noticed a correlation between higher body size and more severe cases of COVID. It's really important to understand that this was just a correlation. They were not saying that high body weights caused the severe COVID they didn't really know what the relationship was, they were just noticing this trend.

That's not how it got reported in the media, pretty much immediately, even within the research community, within the larger medical community and certainly within the media, we started seeing headlines that high body weight equals higher risk of COVID and worse cases of COVID. It was presented as a causal relationship, which is not scientifically true. That's when we started to see this negative bias against high body weights really spiked, because with any of the other risk factors about severe COVID, when we talk about how the elderly are more vulnerable, or medically fragile children are more vulnerable, we frame that as this is a population to protect.

When it comes to the weight, though, because we wrongly assume that weight is a matter of personal responsibility, we blame people for having this higher risk rather than saying what is actually going on with this data, what is this relationship we're seeing and what does it mean? How do we protect, if this is a more vulnerable population?

Rebeca Ibarra: What concrete research or data do we actually have on the relationship between COVID and weight? Is there any out there?

Virginia Sole-Smith: There are a handful of studies that have found this relationship, but one of the best studies was done in California data, they found a relationship between more severe COVID cases, and men with a BMI over 40, they did not find the relationship for women. They did not find the relationship for lower BMIs. The BMI scale counts obesity starting at 30. The lower range of the obesity scale was not impacted, but they didn't see this relationship between very high weight bodies and more severe COVID.

Again, this wasn't a causal relationship, this was a correlation. What the research has not looked at and what we really need good data on is, what is it about being in a larger body that makes you more vulnerable to COVID? Is it something physical about the way your body is functioning, or is it the way your body is perceived by the medical system? Is it in fact weight stigma causing this heightened risk?

Rebeca Ibarra: Why does fat-shaming still happen? Why does it still seem to be this socially acceptable form of discrimination in a way?

Virginia Sole-Smith: Again, I think it comes back to this myth of personal responsibility. People who live in thin bodies, and maybe have never struggled with their weight, or maybe they have, and they've achieved some degree of weight loss, temporarily, they tend to equate their body size with "I did all these things right, I have achieved this through my eating habits and my exercise and my willpower." We have a solid 50 years of research showing that that is not the case, that weight is actually determined by many, many factors, in addition to lifestyle.

Lifestyle does play a small role, but your genetics, your biological processes, the level of restriction you've lived with in the past, in terms of dietary intake, even factors social determinants of health are a huge piece of this, your income level, your other forms of lived depression. To keep framing weight, as a matter of personal responsibility, is wildly incorrect, but it's just baked into the American psyche at this point, and it's taking a lot of work to undo it. Unfortunately, even in the medical realm, where we would hope that doctors would be more informed on the science of this, that bias shows up over and over when we study weight bias and medical professionals.

Rebeca Ibarra: I want to get to that in a second. Do we know how this form of discrimination intersects with other forms of discrimination, whether based on race, gender, class?

Virginia Sole-Smith: Oh, it absolutely intersects. I am a small, fat woman, but I'm also white, I'm financially stable, I have education, I'm a native English speaker. When I go into a medical setting, my weight may be part of a conversation, it certainly has come up from time to time. I don't worry that it's going to become the only conversation because I have these other privileges that enabled me to advocate for myself. For folks who are living in marginalized bodies that are also marginalized for race, for gender identity, sexual orientation, English speaking abilities, the other physical abilities and disabilities, the picture becomes much more complicated.

That's why, again, when we're looking at COVID, we're seeing the communities that are most impacted are the Black and brown communities, lower-income communities, and weight is probably just an intersecting factor there. Again, none of these people are getting the worst cases of COVID because their bodies are in some way flawed, they're getting the worst cases of COVID because they're getting the worst medical care, they're living with this discrimination.

Rebeca Ibarra: Virginia, what's been the role of the media in perpetuating fat stigma, both during and before the pandemic?

Virginia Sole-Smith: Unfortunately, the media has done a lot of damage. Weight loss is a really popular topic, it gets a lot of clicks on the internet, it sells a lot of magazines. As someone who worked in women's magazines for a really long time, I can tell you weight loss is always on a cover, for a reason it sells. Of course, when the pandemic hit, we had two things that happened, we had this early blast of this research, linking high weight bodies to worst cases of COVID.

We had this larger fear at a time when we have so many affairs, that being in higher body weight was going to make you more vulnerable to COVID in some way. Then we also had just the reality of pandemic life, which is that many folks, regardless of body size, have seen their lives change so dramatically, eating habits may have shifted, exercise habits may have shifted, and bodies have changed, because that's what bodies do, our bodies change in response to stress and that's normal.

In our culture, we demonize that and we immediately want to fight it. I think it's a natural thing that when we're feeling out of control in so many ways in our life right now that we look at our body size and our food and our exercise as the thing we should try to control, because we're told over and over again, it should be within our control, despite all the research showing that it's not.

The media has definitely played into this. I'm seeing so many more weight loss stories focused on get back to your pre-pandemic body the same way we talked about women getting back to pre-baby bodies, which is just a really negative concept. On social media, too, influencers are talking about this a lot. There's a lot of jokey memes featuring people in bigger body and presented in really undignified and insulting ways. It's really understandable that this is on everybody's minds. Again, we have to step back and say, first of all, even if it turned out that there was a causal relationship between a higher body weight and COVID, there's no way for you to lose enough weight before you go to the grocery store today to protect you from picking up COVID.

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It's just not something that makes sense to try to do. We know what works to prevent COVID, wash your hands, wear your mask, socially distanced, but in this time of great stress, of course, we're turning to this other thing.

Rebeca Ibarra: Virginia, several states, including New York, where we're both based, have now opened up vaccine eligibility to people with BMIs or body mass index of more than 30. What are your thoughts on that, and what do you make of the backlash to it in some cases?

Virginia Sole-Smith: Again, it's this whole personal responsibility mess, that's feeling the backlash. People are saying they shouldn't get vaccine priority because it's their fault they're in this body, which is false. It's just not how body size works. It's a myth, we really need to dispel it every opportunity.

I am absolutely pro-people in larger bodies getting vaccine prioritization, because we are at higher risk for worse COVID because of fatphobia, because of medical weight stigma we're likely to encounter, and we deserve to be able to vaccinate ourselves against that to protect that. That said, this vaccine and linking those two things is continuing to perpetuate that stigma, because all the lists you see of the comorbidities, it doesn't say, high body weight increases your risk because of weight stigma. It just says obesity. Those sorts of decisions, I think, are definitely driven by stigma and paranoia about weight much more than they are driven by science.

At the same time, though, yes, if you qualify for the vaccine, get the vaccine. The more of us to get vaccinated, the better it is for fighting COVID in general. That's what we need to do in part so we can free up some energy to work on this other issue.

Rebeca Ibarra: We keep saying BMI, BMI, can you tell us how accurate it is actually to measure health in this country based on BMI?

Virginia Sole-Smith: BMI is a hugely flawed system. The original data for BMI, the original formula was invented by a Flemish astronomer and statistician in the 1830s. He was not a doctor, he was not a health professional, and he was not attempting to study health, he was attempting to track what he called the "average size of man."

He developed this formula for tracking height and weight in Belgian men, so white European men that we have then extrapolated to be this system we're using to measure everybody and to equate with health, but the bottom line is, every medical professional would agree, it is not a useful barometer of individual health. It can be useful for tracking population size and then tracking larger population trends. It is not a useful reflection of an individual's health, but we're still using it that way. So, it's really problematic.

It doesn't take into account muscle mass. You have many professional athletes with "obese BMIs," basketball players, football players, that kind of thing, but the real problem to me often you'll hear people say, "I can't believe I have this BMI, when, look, I exercise so much. You wouldn't look at me and think I'm fat."

The real problem is that it continues to equate health and weight. It causes this perpetuating the stigma against folks in bigger bodies. That's the real danger of BMI, is how much we keep holding on to it. It's used to determine whether insurance pays for certain medical procedures, it's kids have their BMIs calculated in school, which can be a horribly stigmatizing experience for children. I've seen myself, it can really shift the tone of a conversation with a doctor, once they have that BMI in their sights, they start only seeing the patient in the context of where they are on the BMI scale.

Rebeca Ibarra: The key words in that BMI study are white men, they used white men as a reference for everyone else?

Virginia Sole-Smith: Yes, because this was the 1830s in Belgium, this is what they were doing, but it certainly has not been properly expanded upon since then, we're still tied to this very archaic formula and using that. Same with pediatric growth charts that use the body mass index, they are mostly calculated based on data collected between 1963 and 1988 on white children, and this is the growth chart that pediatricians are telling parents to measure their kid's health by. So, yes, it's a deeply flawed system.

Rebeca Ibarra: Virginia, lastly, how can we be better as individuals and as a society at pushing back against fatphobia and shaming in our own lives as the pandemic continues and beyond?

Virginia Sole-Smith: One of the best things to do for anyone who feels that this is safe and available to them, because it won't feel safe for everybody, but one of the best things to do is with your own health care providers say, "I don't want to be weighed unless you're calculating a medication that is--" Anesthesia, they need to know your weight to calculate the dose.

The vast majority of times when we go to the doctor's office, we don't need to get on the scale. If we start pushing back on that, which you absolutely have the legal right to do and say, "I'm declining the weight today," that's going to motivate your doctor to say, "Okay, now I have to ask you more questions about your diet and your lifestyle and your stress level and your sleep." That's going to, A, give you a more enriching medical experience because your doctor is not going to be so focused on your weight, whether you're in the normal range or the higher ranges, and it's also going to help shift this conversation away entirely from this weight-centric ideal.

What we really need is a weight-neutral approach to health care, where patients are evaluated on their health on their biomarkers, things like blood pressure, cholesterol levels, blood sugar, and also the things that really determine our health in day-to-day life, or activity levels, or stress levels, or sleep. You can work on all of those issues, you can work on all of those health problems without ever prescribing weight loss.

Rebeca Ibarra: Virginia Sole-Smith is a Journalist and Author of The Eating Instinct. Virginia, thank you so much for joining us.

Virginia Sole-Smith: Thank you for having me.

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