My colleague April Herndon has a new essay up at the Hastings Center's Bioethics Forum, asking whether it makes sense to think about obesity as a disease. I highly recommend it. Here, I ask April a few follow-up questions:

1. 'Is obesity a handicap or a lifestyle?' What is your reaction to that question?

"What fascinates me about this question is that 'handicap' and 'lifestyle' are presented as dichotomous. I think what someone was trying to ask is whether or not obesity is a disease (what they are calling a 'handicap') that someone can't help or a choice (what they are calling a 'lifestyle'). The truth is that obesity is so complicated that most doctors and scientists will admit that the answer may change for each person or (gasp!) that we just don't know. In some cases a person may have some underlying physiological traits that cause obesity or predispose him or her to obesity, traits that are then triggered by environmental factors. Other folks may simply overeat. For some folks, it may be a mix of both. In some cases, we just don't know. Obesity is far too complicated for simple dichotomies. That said, for some people, there's no doubt that their body size becomes disabling; some people lose the ability to ambulate due to their size. Other people, however, may be large their whole lives and never experience any health issues directly related to their size. I guess the short answer to the question is both and neither. Or choose a better question."

2. You suggest that it makes more sense to perhaps think about obesity as a risk factor for certain diseases, rather than as a disease. Can you explain?

"Many people in the medical community believe that obesity raises the risk of certain diseases or conditions but may not necessarily be a health problem in and of itself. Think of it this way: We know that women are more at risk for breast cancer, but we don't consider being female a disease. We know that having light-colored skin and light-colored eyes increases one's risk for skin cancer, but we don't consider lighter-skinned people diseased. Obesity is similar. It may very well raise certain risks for disease, but that doesn't mean obesity is a disease in and of itself. I also believe thinking about obesity in this way is dangerous. While so many people are hyper-focused on the obesity epidemic, there are plenty of thin people eating poorly and not getting enough exercise, both of which are widely accepted risk factors for cardiovascular disease. As long as we stay focused on the size of a person's body rather than the real issues that we know affect health--issues like eating habits and exercise patterns--then we miss all the thin people who are at risk and probably waste a lot of money running tests on obese people who may be large but eat healthy diets and move regularly. In short, I think everyone is put at risk by focusing on obesity as a disease and on large people rather than focusing on what we know to be risk factors for everyone--regardless of their size. How about a war for health rather than a war against obesity? Way more people would benefit."

3. Some people seem to think that stigmatizing fat will make people thin. Do you think stigma works well as a dietary aide?

"First, this assumes that people who are large aren't already eating well and exercising. It suggests that everyone who is obese could and should always be smaller, which doesn't necessarily mean healthier. Again, it puts the focus on someone's weight rather than someone's health. Even if someone thinks being thinner automatically makes one healthier, the idea that the way to motivate folks to be thinner is to make sure they are discriminated against is ludicrous. Here's a scenario: I'm a large woman going to look for a job, and when I arrive at the interview I'm told I don't fit the company's image. Maybe I was told that because I couldn't find affordable and appropriate clothing for work because clothing designers have decided larger women don't need business wear; we only need sweatshirts with bird houses appliquéd on them. I can't get access to good medical care for the most basic of my needs (research shows that many doctors don't want to treat obese patients). I have to deal with the daily stress of knowing I'm despised by my culture and constantly being the punch line of jokes. I could peel this onion all day, but hopefully my point is made. There's nothing about all of this that serves as a dietary aide. Stigmatizing fat puts large people into the most stressful set of conditions possible and then asks them to be among the 5% of folks doctors say will lose weight and keep it off. I got depressed just writing this."

April's last point about the harmful stress that comes from discrimination reminded me of what I wrote about in Straight Life with Rainbow Flag. (Stigmatizing and harassing people is just not a reasonable way to try to leave them healthier!) Please check out April's post.

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