After reading the last page of Fat Talk: Coming of Age in Diet Culture, I cried. Virginia Sole-Smith’s book made me radically question my own beliefs about fatness, health and diet. If you have a child, were a child or know a child, and think even a little bit about what our culture tells us about “good” or “bad” bodies, then this book will turn everything you thought you knew about how to raise a “healthy” child upside down.
We are so convinced that it’s awful to be fat, and especially to be a fat child, that we don’t interrogate what that anti-fatness does to kids, large or small, nor whether we are correct in our convictions. As Sole-Smith writes: “It’s not their bodies causing these kids to have higher rates of anxiety, depression and disordered eating behaviours. The real danger to a child in a larger body is how we treat them for having that body.”
Sole-Smith started looking at the relationship between food, weight and health when her daughter had to be placed on a feeding tube until she was two. She’d developed a food aversion after major heart surgery when she was just a week old, an experience which led to Sole-Smith’s first book about kids and food, The Eating Instinct, in 2018. Fat Talk’s point – backed up by hundreds of expert interviews and years of research – is that our pervasive anti-fat attitude and relentless pursuit of thin-ness have created systemic biases (however well intentioned), which harm people who happen to live in bigger bodies far, far more than body size ever could and which are especially dangerous for children. “We have lots of research showing that high bodyweight correlates with poor health outcomes,” Sole-Smith, a former health and beauty journalist, tells me from her home office in the Hudson Valley, New York state. “But we don’t have good evidence that body size itself causes poor health outcomes.” Weight and health outcomes might both be influenced by underlying issues or root causes – experiencing poverty, food insecurity or oppression, for example. “Sometimes a health issue increases weight, but that doesn’t mean weight loss will fix anything, because body size is just a symptom,” she says.
Experiencing stigma and shaming, discovered Sole-Smith, leads to intense physiological stress responses, actually triggering some of the health consequences sometimes experienced by people in larger bodies – consequences we attribute to body size, rather than our treatment of the people in those bodies. Repeatedly experiencing high amounts of the stress hormone cortisol, for instance, can in itself lead to high blood pressure and heart disease, and can result in weight gain. Sole-Smith also cites reams of recent data on weight stigma in medicine, which often prevents bigger patients seeking treatment until they are very sick, then receiving poorer care when they do, which may in turn skew the data on body size and health and mortality risks. According to a Lancet policy review in 2022, “69% of doctors, 46% of nurses and 37% of dietitians report biased attitudes against people living with obesity”.
The strongest predictors for weight gain in children are weight teasing and being put on a diet; they are also strong predictors for eating disorders, Sole-Smith writes. Being told you’re too fat in childhood is associated with a higher likelihood of an obese BMI later in life. The epidemiologist who first uncovered this, Dr Dianne Neumark-Sztainer, was repeatedly challenged when she presented her 2012 findings at conferences, by medics who assumed she must have made a mistake. “They couldn’t believe that trying to lose weight, let alone just feeling bad about your weight, would result so consistently in people weighing more,” she told Sole-Smith.
It’s not uncommon for kids in larger bodies to show signs of disordered eating, but because we have a clear image of what an eating disorder looks like – thin – they rarely get diagnosed. But atypical anorexia nervosa, in which sufferers are not underweight, affects 3.6% of all adolescents, versus anorexia nervosa, which affects 0.6% of young people. Eating-disorder specialists report that up to 30% of their patients are or have been higher weight, especially in paediatric wards. As one of Sole-Smith’s interviewees, a doctor who treats eating disorders, says to her: “I’m not saying extreme obesity isn’t a problem. But malnutrition will kill you quicker. Restrictive eating disorders kill more kids than diabetes or cancer.” For Sole-Smith, our ineffectual war on obesity hasn’t just made people feel miserable, it is also inextricably linked to the recent rapid increase in eating disorders. According to the London Centre for Eating Disorders, UK hospital admissions for eating disorders have risen 84% in the past five years, with almost 10,000 children and young people being admitted between April and December 2021 (the number of children admitted with – not necessarily for – obesity was roughly a quarter of that number over the same period).
In pointing all of this out, Sole-Smith has sent a few commentators completely off the rails, with them arguing that questioning the received “obesity = death” narrative is wildly irresponsible.
In America, where the book hit the New York Times bestseller list as soon as it was published in May, Sole-Smith has been called a “fat skank” and a “bigoted piece of shit”, and accused of publishing “grifting nonsense”. She’s had plenty of emails, mainly from men, admonishing her for failing to do proper research – “science shows that” is a recurring phrase – but without ever sending a contradictory citation. “‘Please do your research’ is one of my favourites,” she laughs, somewhat wryly. “Because I do research this. For a living. It just shows this is an issue we are very polarised on, and that this bias is tangled up in a lot of fear.” How does that feel? “It is an energy drain,” she says. “There’s a steeling of yourself when you go to open your email. The positive response does outweigh the negative, though. At my first book event, there was a row of health teachers who told me they were there because they want to change their curriculums and be more inclusive. All the following week, when the hate mail was coming in, my mantra was: ‘The health teachers, the health teachers!’ Hearing from researchers saying they’re re-evaluating their protocols because they haven’t been controlling for anti-fat bias in research – that’s huge. Hearing from doctors embracing the book is huge – doctors are a major source of anti-fat bias and can cause a lot of harm. I hear so many eating-disorder origin stories that start with, ‘I was 10 years old at the doctor’s and they grabbed my stomach…’”
Our dislike of fatness and our fear of becoming fat are things we are taught from the first moment we interact with the culture of appearance. As it happens, mine is a smallish body. I would like to think much less about the doming of my stomach, but I don’t experience the horrific systemic discrimination experienced by people living in bigger bodies. The consequences of living in a culture mired in anti-fat bias and its veneration of thin-ness are real for all of us, but my negative self-talk is nothing in comparison to what the roughly 50% of people who are designated overweight according to BMI, experience.
As Sole-Smith points out again and again, there is so much anti-fat bias laced into research around obesity, weight and metabolic health, that it’s unclear exactly how much of the data on the consequences of obesity we can trust (which is why I’m deliberately not repeating any of it here). She debunks, for instance, the still widely made claim that obesity kills 300,000 Americans a year, which has never been true. Fat Talk contains a chapter titled “The myth of the childhood obesity epidemic”, detailing, among other things, how the arbitrary shifting of boundaries on growth charts in 2010 moved a whole cohort of kids out of the overweight BMI group and into the obese one.
Body mass index, or BMI – not weight – is how health professionals designate people as underweight, normal weight, overweight or obese (it’s calculated by dividing weight by the square of height). But it is a blunt tool, primarily useful at population level and was first developed using height and weight data from white men in Belgium in the 19th century, then slightly refined in the 1970s, again mainly using white male data. As a result, BMI is notoriously bad at accurately predicting the health-weight relationship of people from non-white groups and for women. The often-told story is that of the athlete categorised as obese because BMI can’t tell the difference between muscle and fat, but as Sole-Smith notes, it’s more important that it fails to assess metabolic health – how well our bodies process energy – elsewhere on its scale. When other tests are used, around 30% of people at the smaller end have metabolic health issues, while half of people it designates as overweight and a quarter of people it says are obese are metabolically healthy.
Children’s bodies change as they move into adolescence and are highly heterogeneous. BMI is terrible at adjusting for stage of life, which is why it seems flat-out mad to apply BMI to children, and why many campaigners, including Sole-Smith, take issue with the idea that we should be freaking out about children’s weights at all. “BMI doesn’t take the puberty stage into account – which starts at different points,” she says. “So if you’re comparing a white eight-year-old girl who’s nowhere near puberty to a black eight-year-old girl who’s starting puberty, you’re going to demonise the black girl’s body. She’s fine. She’s healthy.BMI being rooted in 19th century white men means we were screwed from the get-go. During puberty, girls have to increase their body fat percentage in order to menstruate. And that is where it starts – we demonise losing the tiny childhood body if you were a thin kid, and becoming a differently shaped adult, and we tell kids to fear it and every bodily change after that. But what if we celebrated them all? Weight gain is always framed as this failure, but why is it a failure, if everyone’s body does it?”
One of the things Sole-Smith wants to explode is the idea that weight is solely about what we eat and how much we move, a belief we hold very tightly, but again, just isn’t true. The eat-less-exercise-more mantra has been repeated so many times that it’s no wonder we struggle to let it go. The reality is much more complex and involves our genetics, our physical and food environments, and our microbiome – all things over which we have little personal control and which interact with each other in ways we do not fully understand. (She does note that moving is important, citing an analysis of 22,746 people in 2020, which showed that being physically active was associated with a larger reduction in heart disease risk than having a “normal” BMI.) “Sometimes, of course, weight does appear to be causal – but even then, pushing weight loss isn’t the answer. Safe, sustainable weight loss is out of reach for most people and the increased risks for disordered eating and the health impact of weight cycling are rarely factored in. Focusing on the ‘dangers of obesity’ costs our health because it leads us to misdiagnose, pathologise and mistreat people when we could be focusing on their actual health needs.
“The willpower myth has been disproved in the literature,” she continues. “The reason weight-loss drugs are being developed is because we know willpower is not enough. But the main pushback I get about this work is, ‘OK fatty, just go to the gym, why don’t you try harder?’ It’s fascinating that the idea is so deeply embedded in us that my body is my responsibility and so it’s my fault.” Similarly, it’s curious that we accept that it’s possible for a person to eat what we might consider a lot and carry on living in a thinner body, but we don’t accept the inverse, which is that some – perhaps many – bigger bodies are bigger for reasons not entirely connected to the amount of food they consume. “Non-pathological human body diversity exists and has always existed,” she says.
Sole-Smith is more relaxed around ultra-processed food (UPFs) than I am, given the new books by Chris van Tulleken (Ultra Processed People) and Henry Dimbleby (Ravenous), plus the recent Panorama documentary that revealed an alarming bank of evidence around food additives. For her, we are so screamingly frightened of fatness that we are, once again, failing to tease apart whether it’s fatness which is the problem, or something else about these foodstuffs, which may do us harm.
“What people are really talking about when they get anxious about UPFs is, ‘If I have that packet of Oreos in my house, I will eat the whole lot uncontrollably, and my children will, and they will get fat.’ That is the underlying fear, that these foods make us feel out of control in a way that equates to fatness. I am fine with critiquing the food industry. But what I want to critique them for is the fact that they are actually selling us restriction. All of the marketing around ultra-processed foods is just the flipside of diet-culture marketing – indulgence. These large conglomerates own both diet brands and ultra-processed food brands, and they’re selling the same thing – you have to restrict, you have to restrict, and then you have to be bad. And because we’re caught in that web; that’s why we feel out of control around these foods.” Sole-Smith has two young daughters, and no food is restricted in her home. “And I can tell you, nobody is out of control around these foods in my house.”
That web makes it hard to determine which of our health concerns for ourselves or for our kids are worth having. “One good question is: ‘Would you be worried about this if you or your kids were guaranteed to always be in a thin body?’” she asks me. “If weight was not part of the conversation and if you knew your child was guaranteed to stay in a thin body and would never experience anti-fat bias, would this be an anxiety? Often there’s some degree of, ‘Oh. Yeah, I wouldn’t care as much,’ which shows you that it’s the bias driving the fear.”
The UPF and obesity debate threatens to erode the gains made by body acceptance movements. We hide fat phobia behind concerns about health and dress it up still more by being concerned about what obesity might cost health services. And yet the government does not seem moved to do what would undoubtedly have a greater impact than any anti-obesity campaign ever has: to research the metabolic impact of UPFs, which may explain the relationship between ill health and diet better than size does; to better regulate the food industry; and to deal with structural inequality and our long-hours-low-pay, always-on hustle culture which makes so many people feel too busy or stressed to eat well.
As well as exhaustive myth-busting, Sole-Smith has a huge amount of practical advice for anyone caring for kids, much of which boils down to us accepting and then teaching them that bodies are all different and all worthy, and that being bigger is not a bad thing. She advocates for trusting children to choose what they eat, allowing them to live by their likes and dislikes, to choose when they’ve had enough, and to say no when they want to, so that they learn to know themselves and their bodies. That, of course, is challenging for anyone who a) grew up in the clean-your-plate era, and b) who believes their children would live on Haribo given the chance (she debunks the science of sugar highs, too).
Modern parenting – and adulting – is riddled with the idea of perfection. What made me cry, after finishing Sole-Smith’s book, wasn’t just the scale of what we’ve got wrong about food and bodies and children over the past 40 years, but also the feeling of hope. “We can make fat into just another body descriptor,” she writes. “And we can make fat good. Because once we know that to be true, we have no reason to keep pursuing thin-ness at any cost. We can stop judging how our kids’ bodies grow. We can reject the premise that our worth, as parents or as people, should be measured by our weight.” What also made me cry was the idea that rather than fixating on how to feed my children perfectly, I might instead be able to make them feel safe inside their own skins, in a way I’m not sure I ever have.
Fat Talk: Coming of Age in Diet Culture by Virginia Sole-Smith is published by Ithaka at £16.99