Vol. 49 August 1, 2011 How Did “Fat” Become “Obese”?

I was really tired of words like ‘plus size,’ ’round’ and ‘large.’ I thought, ‘Come on, we’re fat.’

Kirstie Alley

For the first time ever, overweight people outnumber average people in America. Doesn’t that make overweight the average then? Last month you were fat, now you’re average – hey, let’s get a pizza!
Jay Leno

We used to call overweight people “fat”.  Now they are “obese”.

This now politically-correct nomenclature has emerged from the medicalization of heaviness.

You use to be able to tell when someone was overweight by just looking at them. Now you must calculate their BMI, a measurement derived from height and weight, that superseded the more primitive measurement of skin fold thickness that nobody liked doing anyway. Scientific-looking graphs allow you to plot BMIs on a percentile scale. If your BMI is over the 90%tile you are REALLY FAT, excuse me, obese.

You can graduate from being merely obese to the Metabolic Syndrome with just a few blood tests; triglycerides, cholesterol, and insulin levels. People with Metabolic Syndrome have large belt circumferences; ie. they are fat. If your belt length is over 47 inches your mortality rate is doubled. (1) If you are a man with a belt circumference over 35 inches you are at increased risk for heart disease, stroke, hypertension, and , of course, diabetes. Overweight people tend to develop diabetes, so now all fat people are “pre-diabetic”. In fact half of the U.S. population could be called “pre-diabetic”. This recognized medical diagnosis has changing criteria. Just ask your own doctor what level of blood sugar he or she now considers “pre-diabetic”.

A pediatrician and a lawyer from Children’s Medical Center in Boston recently suggested that really fat children should be removed from their families by the state because extreme obesity in a child should be considered a form of child abuse; a striking example of the medicalization of  heaviness (2). One of the problems with this idea is that “you can’t pick your parents” and obesity does have a large genetic component. If parents are fat, their children will tend to be so also (even if they reside in a foster home).Once you start expanding the definition of child abuse where do you stop? What about parents with more than the  “normal number” of guns in the house. What  is that number? What about parents who watch more than 6 hours of TV a day? More than likely their kids do too, and we know that  prolonged TV watching leads to obesity.

No less a moral authority than renowned biomedical ethicist Daniel Callahan, retired Director of The Hastings Center  (dare I call him a “heavyweight”), has joined the discussion. In “Harnessing Stigma or Stigmatizing Stigma? The Case for Obesity” he proposes that the obese be subject to the same social stigmatization as smokers. The similarities are numerous. Both cause expensive medical illness. Both seem to be the result of individual’s choices. Calorie counts on foods are now required like Surgeon General’s warnings on cigarette packs. Callahan never published the article after public health researchers battling against the stigmatization of fat people changed his mind; i.e he returned to  “political correctness”. (Ah hah! When battling for a cause it is OK to call them “fat”, not “obese”.) Ironically if everyone stopped smoking the improvement in life expectancy would be completely cancelled out by the decreased life expectancy of obesity. If everyone in the U.S. stopped smoking AND returned to normal weight, our average life span would increase by almost 4 years. (3)

The many modes of obesity treatment are only 4% effective. Gastric bypass surgery has great potential for weight loss, though its reasons for effectiveness are still a subject for speculation and research. (4) So unlike smoking which is an addiction and perhaps more amenable to behavioral therapy and temporary medication aids, being fat is “more about the person and less about the behavior” according to Rebecca Puhl, Director of Research at Yale’s Rudd Center for Food Policy and Obesity.

That title definitely plays better than “Yale’s Research Center on Fat People.”      Q.E.D.

1. Arch Int Med 2010 Aug9/23 170:1293
2.State Intervention in Life-Threatening Childhood Obesity    JAMA. 2011;306(2):206-207.
3. NEJM 361;23 22252
4. Lee Kaplan, MD, 2007, MGH Weight Center, MGH)

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