"As a doctor, I no longer know what to do about the obese."

In the late 1980s I spent a year in the US as an exchange student. The exchange organisation allocated me a local support person named Emily. Emily was white and loud and the fattest person I had ever seen outside a caravan park. She looked different from the rare very fat people I’d seen in Australia. She smelt good and her climate-controlled house meant she did not sweat.

She was very well dressed. Her husband was some kind of professional; I didn’t know they even made suits that big. Emily’s family ate like the bejesus. I went to her house once a month for pizza: heavy, oily discs of cheese half a metre across. One each. Before pizza one night I watched the daughter eat a huge bowl of guacamole with a dessertspoon. I couldn’t take my eyes off her. I had no concept of calories; I’d simply never seen anyone eat so much avocado in one sitting. I wondered if it would make her vomit. I kept watching as she put down the empty bowl and turned the page of her novel.

I loved Emily. She cared for me the same way she ate: enthusiastically, generously, without restraint. Her bulk did not disgust me. But I never once ate any pizza. The thought of her pizzas made me sick. All those pools of fat. Twenty-five years later, I am a physician and Australia is filling up with Emilys.

Louise was an educated 35-year-old who had recently lost her high-ranking job and was making ends meet by freelance consulting. Admitted to my ward with pneumonia, she had a high fever and a fast pulse, needed oxygen and was coughing up large amounts of purulent sputum. She was also fat, weighing about 120 kg. I knew that – barring underlying lung disease – obesity was one of the greatest risk factors for life-threatening pneumonia in young people. I felt a responsibility to tell her that her excess fat had harmed her in a way she may not have realised. Every day before my ward round I would say to myself that I was going to broach the subject with her. It seemed a good opportunity to intervene. And yet each time I stood by her bed and looked at her bedside table piled high with literary novels, open blocks of chocolate and teddy-bear biscuits, each time I lifted her pyjama top and pushed my stethoscope into her soft white flesh, I couldn’t do it. I was embarrassed to mention her weight; it felt like I was a puritan taking the high moral ground. It felt mean.

As a doctor, I no longer know what to do about the obese. Australians are getting fatter, and our society is geared towards making them that way — consumption doesn’t just drive economic growth. So is fatness a doctor’s problem? Studies show that verbal interventions during an episode of serious acute illness can result in a change in behaviour – people quit smoking,
cut down on their drinking and sometimes lose weight. But usually counselling people to lose weight is hopeless. Then there are the questions of morality, personal responsibility, associated diseases, resource allocation, quality of life and aesthetics. I have moments of clarity – I think of the way Emily ate – and obesity seems simple: more in than out. Then I am engulfed once again by the high science of genetics, by the concept that obesity is a disease.

I love reading articles with titles like ‘How I Lost 25 Kilos’, even though the answer is always the same: I ate less. Barring the gravely ill and a couple of men, everyone I know wants to lose weight. We live in a society that judges people for being fat, yet has in place every possible means for making them so. Who wants to eat less – of anything when food is so good and plentiful? It’s hard to say no to something that is right in our faces, promising a bit of easy pleasure. It is especially hard to say no when the consequences of overeating come about in such a distant, gradual and mysterious way. I find it difficult to believe that an extra scoop of ice-cream will end up as fat somewhere on my body, even though I know how it happens at the enteric, metabolic and cellular levels. Perhaps this is what happens when we reach the head of the queue and order too much: a fantasy where eating has no consequence, where that pile of French fries and the burger with extra cheese are not our future bodies.

Battles with our appetites and with our bodies are played out on television, in magazines, in the workplace, in families and in hospitals. Be fat in public and you will be weighed by strangers’ eyes. The most radical thing on television this past year was the ordinarily flawed 70-kilo naked body of Lena Dunham in Girls: little girlish tits above big soft lumps and bumps. How shocking: the protagonist has a paunch and eats cupcakes in the bath. She blatantly displayed her body, a lone counterpoint to the usual stick-insect romantic heroines.

Watch Lena Dunham in a teaser for Season 5 of Girls below. Post continues below.

I have heard people say thinness is beautiful and coveted because it is difficult to achieve and rare now, the way curves apparently appeal in times of famine. There are activists who have set out to challenge the fat-is-ugly paradigm, to
curb all this body hatred. I am sympathetic to many of their aims. However, their attempts to manipulate what we find beautiful have been crashingly unsuccessful. The Adipositivity Project – which uses artful photographs of morbidly obese half-naked models to reframe fatness as a thing of beauty —remains separatist and marginalised. And the occasional cover shot featuring a so-called plus-sized model is hardly cause for jubilation. These models – often thinner than the nation’s average – are freakishly well-proportioned Amazons with flawless faces. The pro-fat bloggers are smart, sassy and pissed off. I’d hang out with them. Yet, if they could click their fingers and be thin, would they? Would Lena Dunham? “I don’t want to be skinny like a model,” I’ve had more than one patient tell me, “I’d just like to look like Kate Winslet.”

I don’t know if there is any force that could purposefully change a culture’s definition of beauty. Is fat inherently ugly? Ask Aristotle, Susie Orbach, Naomi Wolf. Their answers are different, their arguments from different places. It is not an empirical question although it reads as one. Today when we look at those who are thin, part of what we see is a triumph of will over gluttony, so the beauty is a moral beauty; it has little to do with health.

This is an edited extract from Fat City by Karen Hitchcock, published by Black Inc. Books as part of the Short Blacks series and available now.