Obesity as Illness
Despite the overwhelming scientific evidence, why do people find this idea offensive?
Lately it seems like one falls on a spectrum between the two following views:
- Fat hater: someone who goes around laughing at and discriminating against the overweight and obese
- Subtype of fat activist: someone who promotes fat as beautiful and states that there are minimal health effects from obesity
I am going to offer, as a doctor, a different perspective that is supported by scientific evidence, that is, of obesity as illness, and then tackle why this concept is and has been so controversial despite the evidence. I’m not going to describe treatment in any great detail as it’s beyond the scope of this article, but instead refer you to WebMD, the Cleveland Clinic, the National Institute of Health, the Australian Government and the Cochrane Review guidelines (there’s 142 of them at this posting!) for further information.
The American Medical Association recently published a statement declaring obesity an illness and calling for a variety of measures to combat this illness of pandemic proportions.This statement builds on decades of evidence about the disorder.
Obesity affects many countries, poor and rich. According to the World Health Organisation, 35% of adults aged 20 and over were overweight in 2008, and 11% were obese. 65% of the world's population live in countries where overweight and obesity kills more people than underweight.
Firstly, what is obesity? Obesity and overweight are traditionally defined using Body Mass Index:
- Normal: BMI of 18.5 to 25
- Overweight: BMI of above 25
- Obesity: BMI of 30 or over
- Morbid obesity: BMI of 40 or over
- The new category of ‘super obesity’: BMI of 50 or over.
BMI does however have drawbacks- notably in non-European people, athletes and people who happen to be naturally slim or stout. More recently, waist circumference- the distance around your stomach measured at the crest of your hips- has come into use as another tool to use along with BMI; more than 100cm is obese.
Secondly, what is a disorder? A disorder, according to Stedman’s Medical Dictionary, is:
A disturbance or derangement that affects the function of mind or body, such as an eating disorder or the abuse of a drug.
Obesity fits this definition. Obesity is not just “being fat” or “being heavy”. There are a range of systems the body uses to maintain itself that become abnormal in obesity.
Put it this way- as one of my lecturers cunningly pointed out to us at university, the amazing thing about our body is not that we put on weight when we eat too much, but that given how much what we eat varies, just how little we do. The body has a battery of ways of matching our input to our output, from feeling full, to not being hungry, to having ‘more energy’, to insulin levels and other hormonal controls.
In obesity, these natural checks and balances have become overwhelmed or altered; what our body senses as ‘normal’ may be markedly abnormal.
Fat cells (adipocytes) themselves multiply to accommodate this extra energy. Because there are more of them, they signal a need for more energy via hormones such as leptin, perpetuating the cycle. Sadly, losing weight does not mean that you lose fat cells; they just shrink. Similarly, the thyroid, which regulates metabolic rate, thinks that being obese is the ‘normal’ weight and slows metabolism in response to weight loss.
Sex hormone levels- both oestrogens (female) and androgens (male)- become altered. Fat itself causes increased creation of oestrogen and reductions in testosterone in men. Abdominal obesity in women causes increased levels of androgens.
Levels of cortisol, a stress hormone, increase in obesity. In morbid obesity, there is continuous low-grade inflammation. These things can make people feel pretty unwell.
There is a well-established increase in blood pressure, cholesterol and insulin resistance in obesity even if those measures fall within the normal range. By this, I mean that if someone with a normal or low blood pressure or cholesterol gains weight, their blood pressure and cholesterol increase, though they may not be so high that they are abnormal according to standard lab values.
And of course there are the myriad things for which obesity is a risk factor: hypertension, high cholesterol, diabetes, heart disease, gallstones, arthritis, sleep apnoea, various cancers, fatty liver disease, infertility.
In summary, obesity is not just a risk factor. It is a disorder in its own right, and it is a self-perpetuating one. “Just losing weight” is not as easy a proposition as one may think- to do that you have to fight your body’s new and unhealthy balance.
Why do people get fat in the first place? Surprisingly, perhaps, people exercise as they did 20 or 30 years ago and are still becoming more obese. This implies what we put in our mouths may be a bigger factor.
The main culprit is the modern diet. It’s full of high energy, low nutrition foods available in abundant quantities. In many places, buying healthy fresh ingredients is more expensive than buying fast food and other low quality, unhealthy food. Soft drinks, juice, potatoes and other foods with a high sugar content are being implicated more and more. If you don’t pay attention, you don’t even realise that some of the things you eat are in fact high in added sugars and fats.
The culture around food and the messages we give kids is also tailored to a past when starvation was more common than obesity. “Come on, another mouthful,” we say, “you won’t grow if you don’t eat your dinner.” At restaurants if we leave some of the unhealthily massive portion on our plates, the wait-staff ask if there was something wrong with the meal. Television is filled with advertising linking high energy foods with health, happiness, convenience, toys and entertainment.
Disordered eating is common. Long work hours, shift work, eating on the run. Eating in front of your work, your computer, your TV. Comfort eating after a breakup. Starvation diets just before a wedding. In addition, psychiatric conditions often cause weight gain and weight loss and that’s before even considering eating disorders.
However, changes in diet and exercise level are unlikely to be the only factors for the scale of this epidemic, and one thing that points to this is the increasing obesity of animals. Increasingly there’s evidence the design of our buildings and communities, environmental industrial hormone exposure, smoking and diabetes in pregnancy and other previously poorly recognised factors have a role.
And a note here: there are also medical conditions and drugs that themselves cause obesity. Hypothyroidism, Cushing’s syndrome. Important conditions. Steroids for asthma, antipsychotics, antidepressants, antiretroviral drugs for HIV. Not exactly optional medication. Genetic factors- which would have been a survival advantage when starvation was a significant risk- and gene expression factors are currently not correctable.
Given the wealth of information here, the overwhelming evidence that obesity is a medical problem, a disorder that results from problems from the environmental to community to individual to organ to genetic levels, why do we insist that this is a moral issue?
Why do I hear people disparaging fat people as ‘lazy’, ‘ugly’, ‘whales’ and ‘wasting healthcare money’? Why do I hear that ‘the health risks of obesity are overstated’ and that calling obesity a disease is ‘wrong’ or a ‘conspiracy by the medical profession’?
We would never say that a cancer patient or someone with lupus is an ‘ugly’ person who was ‘wasting healthcare money’ (even though these are disfiguring and expensive conditions).
We would never say that ‘the health risks of lupus and cancer are overstated’ and that calling lupus or cancer a disease is ‘wrong’ or ‘a conspiracy’ (even though a lot of anxiety accompanies these diagnoses).
That is because health and illness are not moral issues. They are health issues. Framing them as about morality is small-minded and ignores both the causes and the solutions and is extremely unhelpful for both society and the ill person.
For the ‘fat hater’, acknowledging that obesity is a significant health problem is a threat for a bunch of reasons:
- Having to admit that you were wrong
- Having to admit that you are a nasty, superficial person
- Having to admit that some people in the world need more help than others and that that isn’t their fault
- Having to take responsibility as part of a community that is creating obesity
- Not being able to feel superior to someone else
For the ‘extremist fat activist’, acknowledging that obesity is a significant health problem is also a threat for a bunch of reasons:
- Thinking that when people say obesity is a disorder, they are saying the people with the disorder are bad people
- For some people, having to admit that you have a disorder that you have not sought medical help for
- Thinking that when people say obesity is a disorder, they are taking attention away from other healthy things that obese people can do other than ‘just lose weight’ (which is hard)
- Thinking that saying obesity is a disorder means blaming people for not losing weight
- Thinking that someone with ‘an illness’ cannot be seen as beautiful
For the ‘fat hater’, I say this: your ignorance, petty-mindedness, nastiness and refusal to see the real issue is creating more obesity by continuing to support the underlying problems that cause obesity. Eventually if you and the rest of the world continue on this path, you will be outnumbered.
For the ‘fat activist’, I say this: the issues of fighting against discrimination, promoting healthy body image and a healthy lifestyle are incredibly important, please keep up the good work. But so is helping people achieve good health in other ways. Ignoring the health effects and disorder of obesity means denying access, treatment and health to people who need help. Saying that someone is ill does not mean they are not beautiful or good or competent or that they don’t do things to improve their health.
The best results in terms of health and obesity are achieved when we take a look at improving all types of health. Psychological health, healthy lifestyle, healthy diet, exercise, quitting smoking and in appropriate cases medication or surgery (especially when there is another medical condition). Support groups, dieticians, psychologists,doctors, community groups. Architects, engineers, environmental chemists, businesspeople. It’s a complex problem and it will require a complex set of interventions.
We’re all in this together.
