Pattie Thomas, Ph.D.

Pattie Thomas Ph.D.

I Take Up Space

Dear APA: Fat Is Not a Symptom or a Disease

Confusion over risks, symptoms and causes leads to bad practice.

Posted Jun 13, 2012

I am a sociologist. I majored in Psychology in undergrad (actually Interdisciplinary Social Science with cognates in Psychology and Women’s Studies) but I am not a part of the American Psychological Association (APA) and I do not mean to represent myself as an expert on things psychology even if what I do does bump up against psychology as both a discipline and a practice.

Having said that, I am concerned with what the APA does because it has incredible influence over not only the daily lives of people seeking help but the culture as well. Psychology is influential in contemporary society and, as such, should uphold a strong ethical practice in its policies.

Currently, the APA is engaged in the development of Clinical Treatment Guidelines for obesity. In doing so, it has ignored a major voice that should be considered if an ethical and scientific stance is desired: it has ignored the voice of fat people.

This is history repeating itself and not in a good way.

Anyone who knows the history of “treatment” for homosexuality, knows the amount of suffering that was caused when psychologists decided to make a natural human variation into a pathology. I contend (and so do a lot of other people) that fatness is a natural variation of human size.

Fatness Is Not a Disease, a Disorder or a Symptom.

There is no evidence that fatness, in and of itself,  is a disease, a disorder or a symptom. I know some of you are going to cite a bunch of studies about comorbidities and risks. But these do not prove a disease or a disorder. These studies have demonstrated correlation and not much else (and many quoted studies barely do that when you really look at the data).

So let’s get some terms straight because this confusion has led to some bad practice before and will so again. The usual line of studies that are referenced to show how bad being fat is, are about risk factors not causes.

A “risk factor” is an epidemiological concept that was meant to aid in the prevention of a communicable disease or to slow down the spreading of disease. Epidemiology does not deal in cause and effect as much as in patterns in data. The first modern epidemiological study was made in the 19th century by a man named Dr. John Snow, who basically figured out that the source of a cholera epidemic was a contaminated water pump in London. Through showing the patterns of the incidences of the disease he convinced the authorities that they should close down a water pump on Broad Street. It worked.

The water pump was not the cause of the cholera. It was the source of the contamination but not the contamination itself. The pattern merely revealed the possibility and the ending of the epidemic after the water pump was locked confirmed it.

Risk factors are population-level studies. For certain, a number of people drank water from that pump and did not get cholera. For certain, a number of people drank from other places and got cholera. The individuals needed to be treated for the disease. As we later came to understand, they needed antibiotics.

The symptoms of cholera are horrendous, with people literally dying of extreme dehydration due to dysentery, vomiting and high fevers. The risk factor was drinking the water. Drinking the water from the pump was highly correlated with getting cholera but it was not a symptom of cholera. The water was a carrier of bacteria that led to the illness. The cause was the bacteria. By knowing that the pump was a common factor, shutting off the pump helped, but it did not cure the cholera. It lowered the risk, but only for those who didn’t drink contaminated water elsewhere.

Confusion over correlation, risk factors, symptoms, and causes are easier to sort out when there is a clear one cause, one disease situation. This is what allopathic medicine was made for: figure out the one germ that is causing the symptoms and figure out how to stop that germ. In this situation, risk factors are identified to keep people from coming in contact with the germ in the first place. Thus risk is about prevention.

But in today’s climate of healthism and lifestyle public health, where chronic and disabling conditions do not have clear single causes that can be cured, these concepts get quite muddled.  Natalie Boero’s new book (available for pre-order, coming out in September), Killer Fat, delves into the transformation of risk factors into causes by reviewing the Healthy People initiatives that have marked public health since the 1980s. The movement to the understanding of risk factors as controlling disease has political ramifications. It is far easier as a government bureaucrat to look like you are doing something if you concentrate on cheaper “lifestyle” programs than real preventative measures such as vaccines, health care access, hygiene practices, and social factors.

Cover of the book Killer Fat by Natalie Boero, people running in panic

I am certain there is a lot of money to be made in the proposed APA guidelines. The panic level around obesity has been ramped up for nearly 2 decades, since Koop’s “war on obesity” began. In many ways, the APA should be commended for resisting this bandwagon for as long as it has. But apparently the manufactured demand for “treatment” is too great and now the APA is succumbing to the pressures that will inevitably lead to more damage than good.


Treating Fatness as a Mental Disorder Will Fail

Here’s why I believe making fat a disorder or a symptom of a psychological disorder will do more harm than good: It will fail.

It will fail just like aversion treatment for homosexuality failed. It will fail just like dieting fails. It will fail because you cannot treat something that is natural human variation without stigmatizing the people you purport to help.

I, personally was very fortunate in my own mental health journey. I was given a perspective on fat from a vocational rehab psychological counselor who understood the social ramifications of calling my body a bad thing, a symptom, or a disease. I sought out this counselor as a second opinion because when I read the notes of the first voc rehab counselor, I was already trained enough to recognize the classist aspects of her “diagnosis.” The first counselor didn’t write about my history or my concerns or even what I said. She apparently based her diagnosis on my “shabby” appearance, including a lot of notes about my body size and the clothes I wore. I was poor at the time and really not so fat, but she was sure that my k-mart wardrobe was an indication that I didn’t know how to care for myself. I was aghast and requested a second opinion.

The second counselor refuted everything that had been said by the first and then introduced me to the idea that accepting my body and loving it would be a much more fulfilling growth process than trying to change myself or how I looked. She showed me how judging by appearances were an indication of the beholder’s bigotry and not my mental health. Yes, I had issues, but deciding I didn’t know how to take care of myself because I couldn’t afford the best clothing was a symptom of cultural prejudice and stigma. She helped me see that my lived experience should be the source of my strength, not compliance to arbitrary standards. Her counseling changed my life and led me on a journey that included earning my Ph.D.

Treating fatness is treating a physical appearance and as such, it has no business in the APA guidelines. Anything associated with being fat, including mental health issues, can be treated without marking it as “obesity.”

Ethics Demands that the APA Listen to Fat People

If the APA really wants to ethically address questions of fatness and psychology with helpful guidelines for its members and doesn’t want to be revoking everything it does right now in 20 or 30 years, and thus repeating history of its treatment of sexual orientation, I would offer a simple suggestion. Listen to fat people, especially fat people who are researchers, activists, artists and cultural creatives who are speaking out about the stigmatization of fat people.

Killer Fat would be a good first recommendation as I believe Boero’s discussion of how fat became equated with poor health (and all the cultural, social and political ramifications of this equation) outlines the thinking and interests that may be leading to this effort within the APA. Boero’s book also includes research on dieting groups and weight-loss surgery, interviewing alumni from several approaches to weight loss that shows the personal and social construction of fat, weight and weight loss. (If APA task force members want to know more before the book's release, I highly recommend contacting Dr. Boero. I'm sure she would be happy to offer advice and provide recommendations of others they could interview to get a balanced perspective on the questions they are addressing.)

I'd also suggest that they pay attention to the petition.I also know letters of concern have been sent from within the APA. These voices are not fringe. Treating them as such will be to the detriment of the APA in the long run.

And, finally, seek out members of the APA who practice Health at Every Size® and promote a well-balanced life. Listening to the constituency, that is fat people themselves, will create the possibility for a valid statement on weight, fat and psychology to help APA members treat their fat clientele. Not listening will signal a paternalism and stigmatization that can only harm the very people the guidelines are proposing to help.

Dear APA, it is not to late to learn from the past.