Abstract
Assumptions about obesity—e.g., its connection to ill health, its causes, etc.—are still prevalent today, and they make up what I call the medical model of fatness. In this paper, I argue that the medical model was established on the basis of insufficient evidence and has nevertheless continued to be relied upon to justify methodological choices that further entrench the assumptions of the medical model. These choices are illegitimate in so far as they conflict with both the epistemic and social aims of obesity research. I conclude the paper with a partial solution to these epistemic and social shortcomings.
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Notes
For example, Xavier Pi-Sunyer was elected chair of the NIH task force on obesity in 1995 while simultaneously serving as a member on the WHO panel. During this time, Pi-Sunyer also served on the advisory board or was a paid consultant to several diet and pharmaceutical industries like Wyeth-Ayerst labs (the creators of the notoriously dangerous diet drug Fen-Phen that ended up causing heart valve damage), Knoll, Eli Lilly Pharmaceuticals, Genetechn, Hoffman-La Roche, Neurogen, and Weight Watchers International (Oliver, 2006).
See, for example, Bellizzi and Hasty (1998), Giel et al. (2010), Vanhove and Gordon (2014), Tirosh (2012) and Roehling (2006) on ways in which people in larger bodies are discriminated against on the job market or in the workplace. See Sabin et al. (2012), Schwartz et al. (2003) on the prevalence in which doctors and obesity experts employ both implicit and explicit anti-fat biases.
Though the terms “overweight” and “obese,” are often used to describe people in larger bodies, fat activists consider it a slur (Chastain, 2020). For that reason, I will often use the phrase “people in larger bodies.” However, when explaining beliefs, assumptions, or ideas made by obesity researchers (including my characterization of the medical model), I will use the language that researchers use for clarity and accuracy (in scare quotes). The distinction, for example, between “overweight” and “obese” matter for accurately reporting obesity research. I will also refer to the “condition” as “obesity” and refer to the relevant kinds of research as “obesity research.”.
It should be noted that fat activists are reclaiming the word fat, which is taken to be a political identity, to contest shame, express power, and expose the limitations of the medicalized language (Cooper, 2016). Should obesity researchers incorporate the perspectives and testimonies of fat activists in their research (as I recommend in Sect. 4), there may be hope for abandoning the medical model, and with it the stigmatizing language it employs.
I do not think medical professionals consider people who are “underweight” to be healthier than those who are “normal weight” or heavier. This is why I add the quantifier “above a certain threshold.”.
As Alexandrova (2017) argues, concepts like “health” and “well-being” are partly normative and partly factual in that their definitions and measurements depend on moral claims about what is required to be healthy or have adequate levels of well-being. Thus, many claims found in obesity research (and the medical model dogmas) may be considered what Alexandrova calls “mixed claims” in that these statements are essentially “scientific hypotheses that rely on both factual and normative categories” (Ibid.,79). Even the terms “obesity” and “overweight” are in themselves value-laden. Measurements may not be value-laden on their own and without reference to some kind of ranking or classification system, but when such measurements are used to categorize bodies as diseased, non-epistemic values are involved.
For example, if a conservation biologist is gathering data to determine if a species is endangered, then she may interpret the count in a way that would justify imposing regulations on hunting or development (Intemann, 2015). The biologist’s value judgements are not used to determine how many species exist, but they may be used to determine the conceptual scheme that will be used to interpret the data. For instance, decisions about what to count as members of a species and what total number of a species is considered troubling will depend on the conceptual scheme employed.
In this paper, I am criticizing the choice of model that provides the background assumptions against which we interpret evidence, which is different from criticizing whether or not the evidence—given the assumption of one or another model—supports a hypothesis. In this section, I provide some historical and educational background on why the medical community adopted the medical model of fatness and the ways values illegitimately influenced this decision, particularly given the social aims of obesity research. I thank an anonymous reviewer for urging me to clarify this point, and I thank Paul Franco and Rose Nozick for helping me formulate it.
As I will discuss in Sect. 3, an inverse relationship between body fat and risk of death has been observed across various illnesses and diseases—a phenomenon that has been called the “obesity paradox.” Though obesity has been said to contribute to the development of certain diseases (e.g., cardiovascular disease), it has been argued that obesity becomes protective against mortality once the disease sets in (e.g., see Lavie, 2014).
It may be the case that BMI could be appropriately used to confirm a doctor’s suspicions that a patient is “underweight,” however, given the very small percentage of Americans who are considered underweight, this method of measurement should not be the norm. Additionally, as noted previously, dogma 1 does not extend to this category of persons.
We all know that obesity is not a transmittable disease, however, these maps were misleading due to the way the data was presented, making it look like obesity was a spreading infection that was migrating from state to state. What the maps actually showed was the percentage of people in each state with a BMI over 30. The real reason states like Mississippi, Alabama, and West Virginia were some of the first states to turn red was because they are located in largely rural and poor parts of the country, not because an outbreak occurred there. This data is also misleading given that states that are geographically large but have smaller populations (e.g., North Dakota) are being viewed as equivalent to those that may appear geographically small but have larger populations (e.g., Pennsylvania). As a result, for a state like North Dakota to turn red only 228,600 people need to have a BMI over 30, whereas Pennsylvania would need a whopping 3,840,000 people. However, by just looking at the map, when states like North Dakota turn red, it makes it appear as though a large proportion of the U.S. population is obese given that a larger proportion of the map has turned red, but this isn’t the correct way to interpret the map.
A report by the expert committee explains how there is no one definition of disease that encompasses all diseases accepted as such, and thus, no symptoms are dead giveaways for classifying something as a disease. A community’s decision on calling something a disease has been “heavily influenced by contexts of time, place, and culture as much as scientific understanding of disease processes” (AMA, Council of Scientific Affairs Report, 2012, p. 4).
This conception of obesity has changed in recent years, as organizations like the World Obesity Federation and The Obesity Society have moved to define obesity as a disease, not as a BMI range or as the accumulation of adipose tissue. The physiological conception of obesity has become more nuanced in the past decade as a more sophisticated understanding of adipose tissue has developed (Cypess, 2022).
I will discuss later the controversy surrounding the AMA’s claim that weight-loss from lifestyle, medical therapies, and bariatric surgery could reduce mortality and improve health. I will also discuss a phenomenon called the obesity paradox, which also calls into question the AMA’s claim that obesity impairs bodily function.
This isn’t to say that there is no association between weight and mobility but rather, there are many people in larger bodies who are mobile and even active. The category “obese” consists of a wide range of body sizes and shapes. Many professional football players and basketball players, for instance, are considered “obese” and yet, they have incredible fitness capacities and are unquestionably mobile (Lavie, 2014). Thus, given the number of people in larger bodies who are mobile and/or active, it doesn’t seem fitting to say that immobility is a symptom of obesity.
Similar arguments have been made by disability scholars to say that it is not the body itself that is disabling but rather, the environment we live in—that is, such arguments support a social model of disability (as opposed to a medical model of disability) (see, e.g., Oliver, 1996).
I should note that as the medical understanding of obesity has become more nuanced, so too have arguments that obesity is a disease. For example, Kilov and Kilov (2019) argue that obesity meets the criteria for disease from both a naturalistic and constructivist conception of obesity. However, these authors make similar conceptual mistakes as the AMA in some cases. They too treat stigma as a harm of obesity rather than that of fatphobia. They also make the unlikely assumption that calling obesity a disease will improve patient outcomes. Given the prevalence of anti-fat beliefs among health care providers (Sabin et al., 2012; Schwartz et al., 2003), simply calling obesity a disease will not change the assumptions health care providers make about patients in larger bodies. I thank an anonymous reviewer for pushing me to mention how the medical understanding of obesity has become more nuanced since the AMA ruling. I would argue that the way current recommendations of healthcare providers and public health organizations are still relying on certain medical model assumptions (see Sect. 5) demonstrates that these nuanced understandings of obesity are not widely held and/or they are not as nuanced as they should be.
Data trimming sometimes occurs when researchers, usually out of good faith, attempt to isolate the effects of obesity on mortality by excluding certain populations from their calculations. For example, researchers often (1) exclude deaths that happen early on in the follow-up period (i.e., shortly after the enrollment period) for the reason that these deaths were thought to be due to pre-existing illnesses, (2) control for the effects of smoking by excluding current smokers and former smokers, (3) exclude participants with other specific health conditions at baseline (e.g., participants with heart disease or cancer), and (4) exclude people who are hospitalized or in nursing homes (i.e., a large proportion of the older population) (Flegal et al., 2004a, 2004b).
I am not denying that there may be an association between poor diet and/or lack of exercise and obesity. However, my point here is to say that the relationship is far more complicated than people typically think. Assuming that people in larger bodies exhibit these kinds of behaviors is problematic given the stigmatization and discrimination that follows.
When calculating deaths that are “attributable” to obesity, the number does not refer to deaths that can be said to have been caused by obesity alone. The statistical excess deaths attributed to obesity will include cases in which “obesity itself may not be the only contributing factor to this statistical excess, but rather a marker for other factors such as sedentary behavior or adverse body fat distribution” (Flegal et al., 2004a, p. 1486, emphasis added).
See Flegal (2021) for a list of all published responses to her critics.
One of Flegal’s harshest critics, Walter Willett, was quoted saying this in response to research suggesting that “it’s better to be overweight” (Raeburn, 2007). He said that about every 10 years this kind of research makes a comeback and “we have to stomp it out” (Ibid.).
This is of course an extreme example of how resistant some researchers can be to evidence that challenges the medical model. I am not at all suggesting that all, or even most, obesity researchers are this resistant. However, it is interesting how “surprisingly effective” the “small number of vocal critics…[were] in raising considerable doubt” about Flegal and her colleagues’ work (Flegal, 2021, p. 78).
See Shanewood (1999).
French and Swain (1997), for instance, understand the aim of participatory research to be exploring and disseminating the views, feelings and experiences of research participants and ensuring that researchers are “accountable to” the participants (27). In contrast, emancipatory research aims “to change social relations of research production” in such a way that participants are in control of decision-making processes that shape their lives (28).
See https://eurobesity.org; I thank an anonymous reviewer for mentioning this example and encouraging me to elaborate on it.
In other words, obesity researchers have taken for granted something that fat activists think is far from obvious (Koskinen, forthcoming). This is very similar to the ways disability activists have directly challenged the dominant personal tragedy model of disability and impairment by expressing pride in their embodiment (Swain & French, 2000).
Some may think incorporating fat activists is problematic because it has been wrongly argued that fat activists are encouraging unhealthy lifestyles and glorifying obesity (Dionne, 2019). This is not the message of the fat activist movement. Other pride movements have not been about encouraging people to be adopt their lifestyles. For example, the purpose of the LGBTQI + movement is not to encourage people to be gay. Rather, the purpose of pride movements is to celebrate a marginalized identity in the face of societal stigma.
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Acknowledgements
I would like to thank the participants at the 10th Annual Values in Medicine, Science, and Technology Conference (May 2022) for their questions and feedback on my presentation. I would also like to thank Carina Fourie, Amelia Wirts, and Conor Mayo-Wilson for their helpful feedback on earlier drafts of this paper. I am particularly grateful to Sara Goering, Paul Franco, and Rose Nozick for their detailed comments and lengthy discussions on earlier drafts.
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Mehl, K.R. The medical model of “obesity” and the values behind the guise of health. Synthese 201, 215 (2023). https://doi.org/10.1007/s11229-023-04209-z
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DOI: https://doi.org/10.1007/s11229-023-04209-z