“Obese” is a bad word—it’s got to go

(Hi folks– sorry for the late Weekends with Womack post; technical difficulties down under.  Thanks for your patience.  Now to the post…)

We use a lot of words to describe large (or large-ish) bodies:

For instance: fat, plump, hefty, bulky, rotund, pudgy, chunky, portly, heavyset, stout—I found 46 synonyms here. Roly-poly may be my favorite one.

Here’s one I don’t think we should use anymore:

Why not? In some ways, “obese” seems less pejorative and less judge-y than those other words. In fact, it’s really just a clinical word, with a precise definition; nothing to be upset about. Most adults with a BMI of 30 or higher are considered obese by medical definition. It’s also easy to determine when it applies. I can weigh myself, measure my height, consult my handy BMI chart (like the one below) and determine reasonably accurately my BMI.

So why do I think it’s a bad word? Two types of reasons, one scientific and one ethical.

The scientific reasons to get rid of “obese/obesity”: the term “obesity” applies to anyone with a BMI of 30 or higher. But why does medicine and public health use this term? The main idea is that if you are obese, you are in a medically deficient state that needs addressing. In particular, you are at increased risk of developing type 2 diabetes, heart disease, some cancers, orthopedic problems, sleep apnea, and some reproductive problems, among other things. Some of these conditions are potentially life-threatening, so losing weight and becoming non-obese is a compelling health goal. That’s the story.

But is it true? No, not as stated above. Not all BMI numbers 30 and above are created equal. In a widely-cited 2013 study, Katherine Flegal and her co-authors found that people with BMIs 30—35 did not have a higher risk of death than people with BMIs in the 18.5—24 range (called the normal range). Higher risks of death were documented in BMI ranges above 35. And lower risks of death were documented for those in the “overweight” range—25—29.

This news was not taken well; medical and public health professionals unleashed vitriolic criticisms. A Nature article on the topic discussed the problem here:

The result seemed to counter decades of advice to avoid even modest weight gain, provoking coverage in most major news outlets — and a hostile backlash from some public-health experts. “This study is really a pile of rubbish, and no one should waste their time reading it,” said Walter Willett, a leading nutrition and epidemiology researcher at the Harvard school, in a radio interview. Willett later organized the Harvard symposium — where speakers lined up to critique Flegal’s study — to counteract that coverage and highlight what he and his colleagues saw as problems with the paper. “The Flegal paper was so flawed, so misleading, and so confusing to so many people, we thought it really would be important to dig down more deeply,” Willett says.

But in fact Flegal’s results have been duplicated and even extended to show that “obesity” just isn’t a useful word to refer to a medical condition. In this article, Ann Barnes cites US data that shows that weight affects life expectancy differently in white women and black women—for black women, weight isn’t a risk factor until a BMI of 40 is reached, vs. a BMI of 30 for white women.

There is a lot more data out there showing that what we call “obesity” is not one category at all—it is a range of different categories that apply differently to groups depending on age, race, ethnicity, gender, income, geographic location, etc. One size-name simply doesn’t fit all.

There’s more to say about this (there’s always more to say…) but I’ll now turn to the ethical reasons not to use the terms “obese” or “obesity”. My friend Stacy co-wrote this fantastic article about the socio-political meanings that have been attached to the term “obesity”, and I quote from their article below:

In this… social and political sense, obesity is associated with powerful negatives, stemming from both long-standing prejudice and recent public health framing. These include epidemic threat, devastating impending costs, tragedy (particularly children routinely dying before their parents), as well as poor character in obese individuals, who are frequently implied to be lazy, to lack willpower, to be greedy, or to shirk personal responsibility. This view is used to legitimize the well-documented discrimination experienced by heavier people, especially women, particularly younger women and girls. For people above normal weight, then, public discussion of obesity is fraught.

Obesity in the sociopolitical sense also became institutionalized fairly rapidly in universities and governments in the late 20th century. There are now obesity strategies, government departments responsible for obesity, obesity handbooks, professorial chairs, university research centers, websites, Twitter feeds, and advocacy groups with the word obesity in their titles. So obesity as an amorphous but potent social and political concept now raises the stakes in many settings, engendering blame, inducing strong feelings, and providing the focus for many people’s professional roles and identities.

In short, shouting “obesity” in a crowded doctor’s office raises alarms, brings on waves of shame, provokes stern and dire warnings, and puts everyone on notice: Something. Must. Be. Done. Now.  But maybe nothing needs to be done.  Or maybe something does need to be done, but what that is will vary a lot, depending on a bunch of complex factors.  It’s not a uniform call to lose weight, come what may.

I know, we can’t solve these problems just by getting rid of the words. But getting rid of them would be a step towards acknowledging that the story about weight, health, and illness is a very complex one, and using “obese/obesity” confuses us, misleads us, shames us and blames us. So let’s get rid of it. When we need to talk about people’s weight, there are lots of other words around—let’s use them instead.