Obesity: How Does a Diagnosis Become a Slur?

Obesity is a slur. This statement framed the opening to a recent symposium at the UC Berkeley School of Public health. The subject was weight inclusive public health. The goal was dialogue to address systemic anti-fatness and racism embedded in public health, medicine, and the food system.

It’s a lot. On one hand a caricature of obesity science props up the idea that obesity is not a real health concern. But on the other, it reflects systematic bias against larger people that pervades our culture – even among obesity researchers and health professionals.

No one seriously advances the idea that a diagnosis of cancer is a slur. So how did we arrive at a place where some people have concluded that obesity is a slur?

Dogmatic Devotion to BMI

In this symposium, Katherine Flegal gets right to the heart of this issue. She explains that BMI is not a measure of health. Rather, it is a simple index to adjust height for weight. Nonetheless, for many people it has become the definitive measure for obesity. It’s convenient because of its simplicity. But as a definition for obesity, BMI serves an insidious role to make body size a medical problem. In the end, says Flegal, defining obesity by BMI promotes anti-fat attitudes and weight stigma.

Folks who study obesity and folks who are serious about obesity care understand that BMI might be a signal, but it is not the definition of obesity. Rather, obesity is a disease of abnormal or excess fat accumulation that causes harm to health. BMI thresholds provide reference points, but they do not work as hard and fast definitions for obesity. Many factors come into play. Weight and height alone cannot define a person’s clinical health.

Thus, Flegal is right. Promoting BMI as the definition of obesity serves mainly to promote weight stigma.

Obesity or Adiposity-Based Chronic Disease?

Notwithstanding the limitations of BMI, the fact remains that obesity is a complex, chronic disease. The accumulation of excessive or unhealthy fat tissue causes great harm to health as a simple matter of fact. It leads to type 2 diabetes, heart disease, liver disease, certain cancers, joint disease, and a host of other problems.

To the extent that a faulty definition of obesity promotes weight bias, it thus adds to the harm of obesity. Because of this, it’s understandable that a community of folks might promote the idea that obesity is a slur. So should we walk away from this word that has been this deeply misunderstood? Clearly that is what the organizers of the Berkeley symposium believe. In 2017, Jeffrey Mechanick, Daniel Hurley, and Timothy Garvey also suggested something like that:

“Adiposity-Based Chronic Disease (ABCD) is a new diagnostic term for obesity that explicitly identifies a chronic disease, alludes to a precise pathophysiologic basis, and avoids the stigmata and confusion related to the differential use and multiple meanings of the term ‘obesity.’”

But the root problem is not semantics. It’s anti-fat bigotry. Neither obesity nor weight bias will disappear anytime soon. Nevertheless, we can work for a better understanding of this disease that has its roots in excess and unhealthy fat tissue. It will not be easy, but healing seldom is.

Obesity is real, but size is not a valid measure of health. So anti-fat attitudes are unacceptable, especially in healthcare and science.

Click here for the Berkeley symposium and here for the proposal for ABCD.

Jesters, painting by Viktor Vasnetsov / WikiArt

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April 17, 2022