Question: “What Do You Call a Fat Woman with a Ph.D.?

Answer: “Fat.”

The answer should be : “Doctor.”

Last week the answer became: “A Disease

Three events this month highlight the ways in which this “us versus them” mentality about fatness permeates our society.

A picture of a cat in a suit holding a diploma, wearing a mortarboard.

An evolutionary psychologist weighed in on obesity (pun intended), earlier this month, when Geoffrey Miller (@matingmind), a professor at the University of New Mexico and a visiting professor at NYU Stern Business School, caught flack for a tweet:

"Dear obese PhD applicants: If you don't have the willpower to stop eating carbs, you won't have the willpower to do a dissertation. #truth." 

Miller is a paleolithic diet believer and his tweet is based upon that theory of why people are the size that they are. There have been some excellent responses to this example of fat-bashing, so I will let you explore them on your own. His tweet, however, demonstrates a kind of profiling rooted in dichotomous thinking about fatness. Either you are fat or thin. If you belong in the former camp, then you are obviously flawed in multiple ways. Not just your body, but your character is impeached by the size of your body, no matter how you got to be that size.

 Neil deGrasse Tyson (@neiltyson), a science educator that I absolutely adore, tweeted a series of quips earlier this month about what you would not say if you understood physics. Among them was:

"Things you might say if you never took Physics: 'I'm overweight even though I don't overeat.'"

 Tyson was called out on this. Since Tyson is not a small person, I found the defense that it “was just a joke” (though that defense was made by fans and not by Tyson himself) interesting. Perhaps, he wanted to poke fun at himself to show he was vulnerable to making poor choices even with a PhD in physics.

But Tyson’s tweet also is also rooted in dichotomous thinking. Either you eat proper proportions in relation to your exercise and are therefore thin, or you overeat and underexercise, and you are therefore fat. The alleged physics of this, of course, is the based on thermodynamics and the calories consumed, calories burned theory of why people are whatever size they are.

Neither the paleolithic theory or the thermodynamic theory is sufficient to explain size variance among humans. Size is not a simple matter of either/or. No nuances were available in these tweets, no room for alternatives or complexities.

Twitter, of course, if not a good venue for exploring nuances or complexities. It is, however, the ease with which these tweets resonated with the twitter world that intrigues me more than the particular persons who sent them. This either/or false dichotomies of thin/fat, good/bad food, health/unhealthy when judging people make for easy references in pithy sound bytes or tweets.

However, in the real world, the implications of highly educated and respected scientists making such jokes and reinforcing such reductionist, dichotomous thinking are multitudinous and impactful. Being fat is a stigmatized status. Miller’s and Tyson’s tweets share a common, underlying theme: fat is a choice, or rather the result of a set of choices. The justification for stigmatizing fat people is that choice.

But this theme does not hold up under scientific scrutiny. Fat is more than a choice.

Current scientific research does not support what the tweets implied. Fat is not simply a matter of what we eat or what proportion of macronutrients we eat. Fat is not a matter of thermodynamics, just energy, calories in/calories out. Size, fat and metabolisms are complex. The overall increase in size on a population level probably has occurred for a multitude of reasons.

Science educator, Hank Green, provides this entertaining perspective on some of the latest science:

As Green points out in the video (click here if you cannot see the video above), even if fat is the result of a set of choices, those choices may have been made long before the individual was born. They are not the fault of the individual and they are complexities that may make the ability to make different choices almost impossible.

In The Obesity Era (Aeon, June 19, 2013), David Berreby, science writer and the author of Us and Them: The Science of Identity (2008), outlines a number of scientific studies that together paint a complex picture of what people come in larger sizes these days: 

In fact, many researchers believe that personal gluttony and laziness cannot be the entire explanation for humanity’s global weight gain. Which means, of course, that they think at least some of the official focus on personal conduct is a waste of time and money. As Richard L Atkinson, Emeritus Professor of Medicine and Nutritional Sciences at the University of Wisconsin and editor of the International Journal of Obesity, put it in 2005: ‘The previous belief of many lay people and health professionals that obesity is simply the result of a lack of willpower and an inability to discipline eating habits is no longer defensible.’ (emphasis mine)

 So many scientists are coming to understand:

  1. Fatness, and more generally, body size is complex and often beyond the control of individuals.
  2. Reducing body size is fraught with difficulties and unknown effects that might actually make things worse in the long run.
  3. Concentrating on weight loss may not improve health in the ways once believed.

What a smaller group of scientists are coming to understand is that trying to “fix” fatness may be motivated by economic, social, cultural and political factors more than biological, chemical and physical factors.

Human beings are a mixture of their biology, their social environment and the consequences of the choices they have made and continue to make. That mixture is hard to quantify and even harder to predict on an individual basis (not so much as a group – group behavior tends to be fairly predictable). 

The AMA declares obesity a disease

All of the above debate was available to the American Medical Association when they met last week to discuss obesity, including the scientific information suggesting that obesity is not simply a matter of personal lifestyle. In fact, some of the reasoning behind the decision to list obesity as a disease is that obesity is not the fault of the individual and therefore, calling it a disease would lift some of the stigma. A fat person isn’t lazy or lack willpower. They are sick.

The biggest objection (that was allowed to be made) to this change was raised by those who believe obesity is just the result of lifestyle decisions. It seems to me that Americans cannot talk about any issue without outlining the “either/or” sides to it and sticking to that simple, false dichotomy. The dichotomy that is being set up in this debate is lifestyle versus disease. The lifestyle people say it is choice or choices. The disease people say it is beyond the control of the patient.

It may very well be that the AMA had its heart in the right place. After all, doesn't calling obesity a disease essentially take the responsibility from the fat person and place it elsewhere? Would removing the blame not also remove the stigma? 

There are times when an official diagnosis from an authoritative body is a good thing sociologically. Schizophrenia was once regarded as essentially demon possession, resulting from a sin committed by the sufferer. Medicalizing the condition and working on treatments has created compassion and tolerance socially where fear and violence once ruled.

Having a name for something, a label, enables people to cope better and provides a basis for social interaction that doesn’t exist without that symbology. This is more than symbolic gesture, however. There are material consequences to such legitimation by an authoritative group.

For example, it will now be harder to discriminate against people of size because of the Americans with Disabilities Act and because the Affordable Care Act prohibits using “pre-existing conditions” in deciding premiums and access to medical care. Certain kinds of services and medications are now tax deductible when they were not before this decision.

So why am I, and other fat activists, not happy with this decision? Simply put, it has essentially declared our bodies as a disease. The only diagnostic measure of obesity is BMI and BMI is a description of a person, not a measurement of an illness. So essentially, like many times in the past, what the AMA did last week was medicalize a stigmatized group. 

BMI is a ratio from the height and weight of a person. So that’s it. Have a BMI over 30 and you have a disease. My husband sits right on the cusp of 30. So basically, if he has a big meal at a buffet here in Vegas one night, he has the disease of obesity. The next morning when food has digested and weight has gone down again, viola, he is cured! This can be repeated multiple times within a year because we go to a buffet about once a month.

So the difference between labeling something like schizophrenia a “disease” and medicalizing the bodies of people with particular physical characteristics, is that the former is a condition that affects the person’s well-being. The latter is a characteristic of that person. Using BMI as a basis for diagnosing disease is what fat acceptance advocate, Nancy Lebovitz calls “BMI phrenology.” Instead of lumps on the head, doctors will use pounds on the scale, but the parallels are obvious.

History will not be kind to the AMA’s decision. Decisions made by privileged groups at the expense of subordinate groups for the profit of the few at the cost of the members of that group are usually doomed to ridicule in generations to come.

When those decisions are “for their own good,” it is usually the opposite. Deciding what is best for a group of people without any understanding of variations within that group (including health habits, health status and genetics, as well as individuality, choice and character) smacks of profiling and paternalism. 

Medicalizing such decisions are usually motivated by greed and profit. The AMA’s decision certainly fits that modus operandi. The AMA decision has increased the market potential of all sorts of health providers, pharmaceutical companies and other “interested parties.” 

Nothing good will come from this decision, even if some short term benefits allow for ADA protections and increased insurance coverage. This is the problem of either/or mentalities.

This decision/debate started with a question of whether size is either thermodynamics or a disease. It is neither.

Not allowing a nuanced debate with all interested parties demonstrates the manifest dichotomy behind fatness in our culture. “Are fat people human or less than human?”

Fatness and fat people are a group that look a like and as such they have been marked by our social system with certain symbolic value. That is all we all have in common. Reducing us down to either “weak” or “sick” is stigmatizing. We remain regarded as “less than human.” 

BMI is a description of a body. The AMA has declared my body and the bodies of people like me a disease. We should have been asked what we wanted and we should have been listened to. Each one of us would have told you right away: “I am Not a Disease.”

About the Author

Pattie Thomas, Ph.D.
Pattie Thomas, Ph.D., is a medical sociologist and author of Taking Up Space: How Eating Well and Exercising Regularly Changed My Life, a sociological memoir.

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