Individuals with obesity suffer serious medical, social and legal discrimination compared with their thin counterparts and this should be opposed. However, some misguided obesity apologists tend to deny the mainstream medical consensus that obesity is a disease and appeal to pseudoscientific misinterpretations of scientific research to prop-up their claims. In reality, preventative research on obesity is highly relevant and the disease-status of obesity is important for giving sufficient medical and insurance attention to a considerable and growing public health issue.
Olivia James is a prolific secular, skeptical and feminist blogger and have written thoughtful posts on websites such as Center for Inquiry, Teen Skepchick, and the Skepchick main blog. James recently wrote a post about biases in science, talking about issues such as confirmation bias and discrimination of minorities in science. A topic that also came up was the medical status of obesity and research into preventative treatments for obesity. This could have been an intellectually credible discussion, but James unfortunately descended into outright science denialism by claiming that obesity is not a disease and that researchers should focus on preventing obesity-related diseases rather than obesity itself. In reality, the mainstream medical position is that obesity is a disease and prevention is key to countering this growing health issue.
The dire consequences of weight discrimination are real
People with obesity suffer considerable stigma and discrimination around the world in a wide range of situations. The first part of the introduction section to Sutin and Terracciano (2013) is highly informative:
There is a pervasive stereotype about obesity in American society: People who are obese are often perceived as lazy, unsuccessful, and weak-willed. These beliefs about individuals with obesity are often translated into negative attitudes, discrimination, and verbal and physical assaults. Such bias can have severe psychological consequences, including increased vulnerability to depression, and lower self-esteem, self-acceptance, and life satisfaction. A broad range of research now demonstrates that the effects of weight bias are not limited to psychological functioning but extend to nearly every aspect of an individual’s life, from employment, and salary disparities, to personal relationships to healthcare delivery. In addition, as with other forms of discrimination, weight discrimination may have consequences for physical health.
Victims of weight discrimination do not only have worse mental health outcomes and suffer social consequences. In a cruel feedback process, people who are subjected to weight-based discrimination are also more likely to become or stay obese. This is in partly because coping processes involve binge eating and the avoidance of physical activity. As if this was not enough, jurors are more likely to consider obese individuals guilty of check fraud and have a high likelihood of becoming a repeat offender compared with their thin counterparts (Schvey, Puhl, Levandoski, and Brownell, 2013).
In other words, weight discrimination is extremely real. It should under no circumstances be trivialized by frivolous and ignorant stereotypes. It should be fought with all reasonable methods.
James on obesity and obesity-related research
In the post about biases in science, James makes the following claims about the medical status of obesity.
Beyond confirmation bias, other kinds of bias can also affect which things get funding or interest for research at all. One great example of this is the fact that many people are researching “treatments” for obesity, despite the fact that obesity itself is not really a disease and their time might be better spent researching the diseases that tend to accompany obesity. This plays directly into fatphobia and is part of the internalized bias many of these researchers have.
In other words, James holds three central beliefs in relation to obesity and medicine: (1) obesity is not a disease, (2) research into obesity prevention is a result of an internalized fatphobia with little scientific or medical merit, and (3) it is better to research obesity-related diseases than to research ways to prevent obesity.
Let us investigate these claims with a skeptical eye and see if they hold up to scrutiny.
The medical status of obesity as a disease
In the middle of 2013, The American Medical Association adopted a resolution that recognizes that obesity is a disease. The resolution in question was introduced by a delegates representing several medical organizations, including American College of Surgeons, American College of Cardiology and the American Society for Reproductive Medicine. They reasoned that a disease is characterized by “impairment of normal functioning”, “characteristics signs and symptoms” as well as “harm or morbidity”. Based on these criteria, the adopted a resolution (PDF, cache) argues that:
[…] Congruent with this criteria there is now an overabundance of clinical evidence to identify obesity as a multi-metabolic and hormonal disease state including impaired functioning of appetite dysregulation, abnormal energy balanced, endocrine dysfunction including elevated leptin levels and insulin resistance, infertility, dysregulated adipokine signaling, abnormal endothelial function and blood pressure elevation, nonalcoholic fatty liver disease, dyslipidemia, and systemic and adipose tissue inflammation. […] Obesity has characteristic signs and symptoms including the increase in body fat and symptoms pertaining to the accumulation of body fat, such as joint pain, immobility, sleep apnea, and low self-esteem. […] The physical increase in fat mass associated with obesity is directly related to comorbidities including type 2 diabetes, cardiovascular disease, some cancers, osteoporosis, polycystic ovary syndrome.
Why did the AMA adopt this resolution? In the wake of the decision, The New York Times interviewed AMA board member Dr. Patrice Harris and obesity activist Morgan Downey and they said that the decision would increase medical attention, help in the struggle against type-II diabetes and heart disease, as well as getting insurance companies to cover for medical treatments related to obesity as such (Pollack, 2013).
The Obesity Society acknowledged that obesity as a disease as far back as 2008. Although they were considerably more cautious than the AMA, they arrived at a similar conclusion (Allison, Downey, Atkinson, Billington, Bray, Eckel, Finkelstein, Jensen and Tremblay, 2008):
The panel concluded that considering obesity a disease is likely to have far more positive than negative consequences and to benefit the greater good by soliciting more resources into prevention, treatment, and research of obesity; encouraging more high-quality caring professionals to view treating the obese patient as a vocation worthy of effort and respect; and reducing the stigma and discrimination heaped on many obese persons. The panel felt that this utilitarian analysis was a legitimate approach to addressing the topic, as well as the approach used for many other conditions labeled diseases, even if not explicitly so. Thus, although one cannot scientifically prove either that obesity is a disease or that it is not a disease, a utilitarian approach supports the position that obesity should be declared a disease.
In 2013, the American Heart Association, American College of Cardiology and The Obesity Society jointly acknowledged obesity as a disease (Jensen et. al. 2013; American Heart Association, 2014):
According to new guidelines released by the American Heart Association, American College of Cardiology and The Obesity Society in November 2013, doctors should consider obesity a disease and more actively treat obese patients for weight loss. The guidelines reflect the latest information that scientists have about weight loss to prevent heart disease and stroke, the nation’s No. 1 and No. 4 killers.
In other words, obesity is a disease according to the mainstream medical organizations and expert groups. Thus, the first claim made by James, that “obesity itself is not really a disease”, is demonstrably erroneous.
The second claim, that the disease-status of obesity is just based on internalized fatphobia instead of real medical merit, can be considered an irrational conspiracy theory. In reality, the medical arguments above has shown that this second argument is also false.
Opposing weight discrimination is a social justice necessity, but doing it with bad arguments is deeply counterproductive.
Prevention of obesity versus treating associated diseases
Obesity-associated diseases such as heart disease, strokes and type II diabetes are among the most common preventable cause of death. Thus, research on obesity prevention can give millions of people better health, longer lives and less medical expenses. In 2008, the medical cost of obesity was close to 150 billion dollars (CDC, 2014). In comparison, the 2008 fiscal year funding for the wars in Iraq and Afghanistan was 190 billion dollars (White and Tyson, 2007). Clearly, there is a considerably individual, medical and economic benefit from creating and maintaining preventative programs for obesity. Thus, the third and final claim made by James that it is better to research obesity-related diseases than to research ways to prevent obesity falls apart.
Obesity apologists like James may offer a number of retorts. They might claim that the fact that mainstream medical organizations accept that obesity is a disease is just evidence that scientific research on obesity is based on “internalized fatphobia” without any medical merit. However, this is both dishonest and circular as it is precisely this claim that is under debate. Merely reaffirming one’s stance is not a valid counterargument.
They might also refer to popular press articles on research on the so called obesity survival paradox that seems to indicate that individuals with class I obesity (BMI between 30 and 35). However, this is not as clear-cut as it first appears. Habbu, Lakkis and Dokainish (2006) points out that clinical criteria of heart failure (HF) might not be as valid in obese study populations because things like shortness of breath and edema may be due to other things and not a reliably indicator of HF. In other words, obese patients clinically diagnosed with HF will appear healthier than their thin counterparts when it comes to objective criteria. So in a twist of irony, obesity apologists appeal to medical research that considers “thin” as the default mold to evaluate non-thin individuals, which is something that obesity apologists rightly think is problematic. The researchers also point out that wasting is common among individuals with a bad HF prognosis. This means that it is not the alleged positive effect of obesity that inversely correlates with HF, but rather the effects of low body weight in people undergoing wasting that correlate with bad HF outcomes. In addition, Diercks et al. (2005) has shown that obese patients tend to get more aggressive treatment (and thus better outcomes) for high-risk non–ST-segment elevation, positive cardiac markers and/or ischemic ST-segment changes (NSTE ACS). This turns out to be another irony, as obesity apologists mistake better treatment given to obese patients with direct, obesity-mediated improvement in outcomes.
The pro-ana connection
Obesity apologists typically believe that obesity is not a disease, but a lifestyle choices. The American Medical Association has very little sympathy for such beliefs. In the resolution they adopted (discussed above), they compared obesity apologetics to people denying the status of lung cancer as a disease:
The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes.
On the other side of the weight spectrum, there exists groups who hold similar views. They are called “pro-ana” and believe that extreme thinness and even anorexia is not a disease, but a positive lifestyle. Although the analogy is not perfect, both of these belief systems have a serious potential for harm. After all, anorexia has the highest mortality of any psychiatric condition and obesity kills over 2.8 million people per year (WHO, 2013).
There are many valid reasons to oppose weight discrimination, but denying the medical mainstream position and opposing preventative research efforts by spreading pseudoscience is irrational and dangerous. It is a serious obstacle for effective social justice activism.
American Heart Association, (2014). Treating Obesity as a Disease. Accessed: 2014-04-18.
CDC. (2014). Adult Obesity Facts. Accessed: 2014-04-18.
Diercks, D. B., Roe, M. T., Mulgund, J., Pollack, C. V., Kirk, J. D., Gibler, W. B., . . . Peterson, E. D. (2006). The obesity paradox in non–ST-segment elevation acute coronary syndromes: Results from the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative. American heart journal, 152(1), 140-148.
Habbu, A., Lakkis, N. M., & Dokainish, H. (2006). The Obesity Paradox: Fact or Fiction? The American journal of cardiology, 98(7), 944-948.
Jensen, M. D., Ryan, D. H., Apovian, C. M., Ard, J. D., Comuzzie, A. G., Donato, K. A., . . . Yanovski, S. Z. (2013). 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. doi: 10.1161/01.cir.0000437739.71477.ee
Pollack, A. (2013). A.M.A. Recognizes Obesity as a Disease. Accessed: 2014-04-18.
Schvey, N. A., Puhl, R. M., Levandoski, K. A., & Brownell, K. D. (2013). The influence of a defendant/’s body weight on perceptions of guilt. Int J Obes, 37(9), 1275-1281. doi: 10.1038/ijo.2012.211
Sutin, A. R., & Terracciano, A. (2013). Perceived Weight Discrimination and Obesity. PLoS ONE, 8(7), e70048.
White, J. and Tyson, A. S. (2007). Increase In War Funding Sought. Accessed: 2014-04-18.
WHO. (2013). 10 facts on obesity. Accessed: 2014-04-18.