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Over the last few decades, several headlines have claimed that “obesity” has increased nearly threefold in America since 1975, declaring an “obesity epidemic."1 Articles detail the purported health risks of carrying excess body fat, such as high blood pressure, and offer losing weight as the ultimate solution.
So why is "obesity" a problem?
This type of framing works to pathologize fatness, essentially marking it as part of the “disease” of obesity. But the problem isn't as much in people's body size as the weight of the stigma they must endure.
Evidence suggests that stigmatizing people in larger bodies is not an effective public health tool. Instead, it's been found to threaten people's health and interfere with adopting healthy eating behaviors.2
The word “obesity” is pervasive and entrenched in our society. In many cases, it even holds a medical connotation, as it represents one of the categories in the body mass index (BMI), a widely used tool in the medical community.
The BMI is a mathematical equation determined by a person’s weight-to-height ratio. The result is then compared to a table of averages—the index—which determines someone's "category," including:19
Underweight
Normal weight
Overweight
Obese
Despite being originally designed to create estimates across large groups or even entire populations, the BMI has gained traction as a measure for individual health in recent years, with physicians potentially basing specific recommendations on someone's results.19
However, some experts are beginning to push back against such widespread reliance on the measure. For starters, a person’s BMI doesn’t consider muscle mass, bone density, fat distribution, biological and environmental factors, and racial and sex differences, which all account for a much fuller picture of someone's overall health.19
Concerns with the BMI as a measure of health
A batch of recent studies have also worked to chip away at the usefulness of the BMI as a tool for individual health recommendations.
A 2013 study indicated that those with a BMI of 30-35 (i.e., classified in the “overweight” range) did not have a higher risk of death than their counterparts within the so-called “normal” weight range.3 While not widely accepted by many public health professionals, the results of this study have been repeated several times.
Furthermore, research has shown that a higher body weight can be a protective factor in certain populations. This includes individuals with respiratory disease, kidney disease, cardiovascular disease, and cancer. Higher-weight individuals have reduced mortality rates with chronic conditions like hypertensive heart disease and after certain surgeries like coronary artery bypass surgery.4,5,6
Some research has found correlations between very high or very low BMI and increased risk of death or certain illnesses. However, this research rarely controls for the impact of weight stigma, fat shaming, weight cycling, and substandard medical care, which disproportionately impact people in higher weight bodies on health risks.7,8 Without considering these critical factors, correlations between BMI and health risk cannot be considered causative.
Additionally, some studies have shown that the statistical relationship between BMI and disease risk differs significantly between Black and White cisgender women.9,10 This is important as most research into weight and health risks is carried out with predominantly white populations.
In addition to unfounded weight stigma, Black women are often subjected to a variety of dehumanizing and racist assumptions from the medical system, including dangerously neglectful pre and postnatal care and reduced access to pain management.11,12,13
"Obesity" as a “disease” pathologizes fat people
Framing fat people as having a disease or medical condition for simply being fat pathologizes—or treats as medically abnormal—these individuals. It contributes to the message, already made pervasive by diet culture, that being fat is inherently bad, immoral, and unhealthy.
Referring to excess weight as a disease gives people an excuse to discriminate against individuals living in higher-weight bodies, allowing them to leverage their discrimination as a concern for the person’s health.
When fat people go to the doctor, they are frequently undertreated or mistreated by members of the healthcare community who misattribute any physical complaint or medical risk factors to the patient’s weight. Doctors may also spend less time with fat patients, provide them with less medical information, ignore symptoms or health complications, and attempt to convince fat patients to lose weight or even go as far as recommending weight loss surgery.14
Between 2006 and 2016, weight stigma increased by 66%
Approximately 53% of higher-weight women reported medical providers making inappropriate comments about their weight or recent weight gain
About 52% of women said their weight has been a barrier to receiving quality healthcare
Approximately 79% of people in larger bodies reported using food as a coping mechanism to deal with weight stigma in healthcare
Weight discrimination can deter many people in larger bodies from seeking both preventative and responsive medical care, which may be responsible for future medical issues or the development of serious health complications, as well as the speed of disease progression. These factors are frequently blamed on weight itself.
Weight stigma leads to shame and mental health consequences
When fat bodies are framed as a medical problem instead of just part of natural body size variation, people living in larger bodies become stigmatized. Many fat people experience bullying, inappropriate comments related to their weight, hostility, and discrimination, all of which can lead to profound shame.
Pathologizing fat bodies and the subsequent weight stigma can cause many harmful effects, such as:2,16,17
In essence, making assumptions about a person’s health status based solely on their body weight, size, or shape only causes further issues—particularly in terms of mental health—which could be prevented by embracing body diversity.
Intentional weight loss is harmful and ineffective
Another issue with pathologizing "obesity" is the related idea of "treating obesity." This makes someone's body shape or weight a thing to be conquered or carefully controlled, which feeds into dangerous messaging in toxic diet culture around maintaining a "healthy diet" and "healthy weight" at all costs.
There is plenty of evidence that proposing strict diets and workout regimens actually achieves the opposite. Weight stigma increases disordered eating behaviors, including binge eating.17 Even dieting attempts that do not result in the development of eating disorders almost always result in individuals gaining back all the weight that was lost or even more.18
At the end of the day, pathologizing fatness is not only harmful and stigmatizing but also ineffective. Instead of medicalizing fatness, the medical community and society at large need to understand that weight is not a predictor of health and instead focus on eliminating weight stigma and creating a cultural and physical environment that better accommodates the existing diversity of human bodies.
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
Disclaimer about weight loss drugs: Within does not endorse the use of any weight loss drug or behavior and seeks to provide education on the insidious nature of diet culture. We understand the complex nature of disordered eating and eating disorders and strongly encourage anyone engaging in these behaviors to reach out for help as soon as possible. No statement should be taken as healthcare advice. All healthcare decisions should be made with your individual healthcare provider.
Resources
World Health Organization. (n.d.). Obesity and overweight. World Health Organization. Retrieved June 29, 2023.
Donini, L. M., Pinto, A., Giusti, A. M., Lenzi, A., & Poggiogalle, E. (2020). Obesity or BMI paradox? beneath the tip of the iceberg. Frontiers in Nutrition, 7. https://doi.org/10.3389/fnut.2020.00053
Fruh, S. M., Nadglowski, J., Hall, H. R., Davis, S. L., Crook, E. D., & Zlomke, K. (2016). Obesity stigma and Bias. The Journal for Nurse Practitioners, 12(7), 425–432.
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