Body fat as metaphor: from harmful to helpful

The dominant paradigm: obesity as pathology

The dominant paradigm sees body fat as pathological. It is seen both as a risk factor for disease and as an actual disease. Pathology as a metaphor for obesity emerged in the late 18th century and has gained traction in recent years. In 1995, the World Health Organization published its technical report 854, suggesting the worldwide adoption of the body mass index (BMI) categories to define obesity.2 The ease with which BMI distributions can be compared across countries and over time led to the publication in 2000 of “Obesity: Preventing and Managing the Global Epidemic.”3 It showed that “obesity” as defined by the new BMI recommendations threatened developed and developing countries alike. Governments worldwide have since tried to monitor and control obesity in their populations and research funding for obesity research has grown along with the number of obesity-related publications.

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Researchers working under this paradigm investigate increasing risks of arthritis, certain cancers, cardiovascular disease, diabetes and death for individuals with a BMI above 30 (the definition of obesity). They also actively pursue studies of weight loss, testing the role of drugs, diets, exercise and surgery to “cure” obesity.

The emerging paradigm: obesity as an ascribed characteristic

This emerging paradigm contests the findings of the dominant paradigm. It highlights its blind spots and suggests that researchers and health practitioners conduct their practices using a “Health at Every Size” (HAES)4 approach: one that de-pathologizes body fat and aims to maximize the health of every person, regardless of size; one within which weight loss is never a goal. Researchers and activists within this suggest that we think of fatness as merely another aspect of human diversity, akin to height, race, gender and sexual orientation, rather than as a disease, and argue that the rights of individuals of all sizes should be protected, just as those of women and racial minorities are protected.

This paradigm stresses how our society’s fat phobia — its irrational fear of, and disgust with, fat — has led to systematic bias in the majority of current medical research on obesity and to the stigmatization of people who are fat, with serious deleterious health consequences via increased stress, poverty and prejudicial care.5

Integrating the paradigms

We do not have to reject all the evidence that correlates obesity and disease to understand the limitations and harmful effects of the dominant paradigm. Fatness, framed as a disease, stigmatizes people who are fat. Framed as an epidemic, it creates cause for alarm and requires action. Beyond alienating patients, these metaphors encourage doctors to evaluate every symptom through a weight-focused lens, and may lead them to ignore important signs of disease and see weight loss as a panacea, ultimately contributing to ill health and early death. A patient who is fat presenting with shortness of breath may, for example, easily be dismissed as too fat for proper breathing function and prescribed weight loss without an examination for other, medically treatable causes of their symptoms.

There is often pushback against non-weight–centred approaches for the health of patients who are fat: Isn’t their weight killing them? Recent research suggests that physicians should exercise caution in applying BMI criteria to evaluate the health status of their patients. A 2008 study of BMI and cardiometabolic risk clustering showed that 31.7% of obese adults in the United States were metabolically “healthy,” while as many as 23.5% of normal-weight adults were “unhealthy.”6 Similarly, a 2011 study showed that BMI barely distinguishes the health risks associated with a BMI of 25 kg/m² from those associated with a BMI of 40 kg/m².7 For someone who is 1.65 m (5′6″) tall, these BMIs are equivalent respectively to 68 kg (150 lbs) and 109 kg (240 lbs); for someone who is 1.78 m (5′10″), 79 kg (174 lbs) and 127 kg (279 lbs).

Physicians are trusted to provide the best possible care for their patients — including encouragement to exercise and eat right — regardless of their race, gender and socioeconomic status. They are also expected to advocate for patients and their health. Why not extend these worthy aims to size? If we were to pay attention to the metaphors we preconsciously call upon when we see patients who are fat, we would be able to acknowledge the biased lens through which we tend to see their health problems and improve our quality of care. Given physicians’ power in society, challenging misguided beliefs about body fat could spearhead a cultural transformation.