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The Medicalization of Weight: Are We "Disease Mongering?"

From the moral to the medical: changing views on overweight and obesity

Skin calipers are an inaccurate way to measure fatSource: with permission with permission
Source: with permission

“There’s a lot of money to be made from telling healthy people they are sick. Some forms of medicalizing ordinary life may now be better described as 'disease mongering': widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments.” So say Ray Moynihan and his colleagues in a 2002 article in the British Medical Journal. Do overweight and obesity fit into this category of "disease mongering?"

What we do know is that overweight and obesity can be risk factors for other diseases. Overweight and obesity are defined by an excess accumulation of fat, as measured fairly imprecisely by body mass index, BMI, (the weight in kilograms divided by the height in meters squared.) This equation, originated by Adolphe Quetelet in the 19th Century, did not come into use as a measure of overweight and obesity until the 1970s--and the norms we use now were not even established until the late 1990s by the World Health Organization. (Skin calipers are an even more inaccurate way to measure fat.) BMI in and of itself, though suggestive of health (the higher the BMI, the more likely health-related issues), does not actually indicate the health of a particular person. Other than an excess of fat, however, there are no other clinical signs or symptoms that are seen in everyone who is obese or overweight. Heska and Allison, in a 2001 article in in the International Journal of Obesity, acknowledge that physicians cannot even predict who will necessarily develop an overweight or obesity-related health problem, of which, of course, there are many (e.g. cardiovascular disease, type II diabetes, various metabolic disturbances, hypertension, certain forms of cancer, osteoarthritis, sleep apnea). These authors note that, even though obesity is a public health problem, there are, in fact, overweight and obese people “who will live long lives free of any of the morbidities known to be influenced by obesity." Heska and Allison add, "We are therefore placed in the conceptually awkward position of declaring a disease which, for some of its victims, entails no affliction.”

There have been significantly more references over the years to overweight in both the lay press and the medical literature, and according to Jutel, writing in the journal Social Sciences and Medicine (2006), the references have shifted from sign or symptom to disease entity. Jutel makes the point that two important factors have contributed to making overweight into a diagnosis: the importance of measurability in establishing health and disease and a strong emphasis in Western society on normative appearance. For example, scales for weighing did not even enter the physician’s office until the end of the 19th century. Jutel believes that overweight is not necessarily a disease “any more than slenderness is an indication of health.” In other words, it is merely “a description of physical appearance.” Domain
"Gluttony," from painting by Hieronymus Bosch.
Source: Domain

Chang and Christakis, in reviewing how one classical medical textbook wrote about obesity in subsequent editions throughout the years of the 20th century, noted that though the basic model of obesity was always seen as a result of excess calories over expenditure, there were different causal factors superimposed. Over time, obese individuals were progressively held less responsible for their condition in subsequent editions of the textbook--from fat as a personal or even moral failing to the medicalization of fat as a sickness. Remember that gluttony and sloth are two of the "Seven Deadly Sins."

Abigail Saguy, in her book, What’s Wrong with Fat? explains that the word “obesity” implies a medical frame, which, in turn, “implies that fat bodies are pathological.” Saguy continues, by “framing fatness as a matter of health raises the stakes. No longer is it a question of appearance, fatness becomes a matter of life and death.” And Dr. David L Katz, Director of the Yale University Prevention Research Center and Editor-in-Chief of the journal Childhood Obesity, wrote in a recent editorial (February 2013), “...weight per se was never what mattered....what makes shape and size problematic is they are often harbingers of ill health....” “What matters here is health. Everything else is fashion.”

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