Updated: May 12, 2005

"It's one thing to lose weight when your doctor tells you to, another when you can't find a pair of pants to fit you."
-- Arthur Caplan, bioethicist, University of Pennsylvania

In the past decade, there has been a great deal of backlash from overweight people. This has come in response to an increasing awareness by overweight people of social, cultural, and professional discrimination directed at overweight people. And they are right. There is a lot of discrimination against overweight people on the streets of the cities and in the offices they work in.

The North American Association for Fat Acceptance, or NAAFA, is, perhaps, the most vocal of the groups. Some, including myself, might refer to them as downright "militant." Another is the American Obesity Association, or AOA.This is the more "politically correct" group. Whereas NAAFA is strenuously active in fighting the characterization of obesity as a "disease," the AOA recognizes the medical significance of obesity and is working to get funding for better research, treatment and prevention. At least, that is my interpretation of the two groups' web site and the individual statements of purpose. The Council on Size and Weight Discrimination and the International Association of Size Acceptance are somewhere in between NAAFA and the AOA. They also actively fight discrination based on weight in work and the insuirance industry. And good for them.

But, the well-intentioned folks of NAAFA remind me a great deal of the "smoking advocacy" groups that arose when legislation first tried to restrict smoking behavior. First, the government cut back on who could legally buy cigarettes. Then, legislated against smoking on public transportation - airplanes, buses, etc. Next, smoking was restricted in government buildings. There was no smoking allowed in courthouses, licensing offices, and the like. Then, private establishments like restaurants and offices, feeling empowered by the moves made by the government, moved toward becoming non-smoking establishments. And the change in cultural attitudes changed the incidence of smoking in our society. And, with the removal of opportunities to smoke, and the resultant decline in the incidence of smoking, came the health benefits: reduced risks of cancer, emphysema, and associated disorders.

Every step of the way, people who were already smokers (and a few of the "libertarians" who resist anything the government plans to restrict) established groups and "smoking advocacy" associations. They protested, they circulated literature disputing the clear medical evidence that smoking was a health risk, they organized letter-writing campaigns, they fought back. They blamed the Congress, doctors and, particularly, the pharmaceutical industry for using "scare tactics" to sell and market new drugs. Of course, they received a "wink and nod" from the powerful, extremely well-financed smoking industry. But, fortunately, persistence and scientific fact prevailed. And the incidence of smoking continues to decline and be less socially acceptable and, most importantly, kills fewer people. Now, as the pendulum swings full circle, the states and class-action lawyers are winning huge settlements from the tobacco industry for damages and to recoup health care cost of victims of smoking.

NAAFA seems to be saying that there is no scientific evidence, just like advocates said in the 1960s about smoking, that being overweight shortens (or even effects) the lives of the victims with this disease. The only thing that affects the obese person, according to some of these groups, is society's pressure on them to lose weight. One of their catch phrases is "don't assume causation from correlation." [Read the article yourself for more clarity.] They refuse to believe the overwhelming stacks of clinical studies associating obesity with early heart disease, osteoarthritis, diabetes, ad infinitum. They refuse to even accept that living a healthier lifestyle with the goal of losing weight. In fact, some of their statements appear to say that losing weight, not being overweight in the first place, is the biggest health risk facing the obese person. Does societal pressure to lose weight increase the incidence of eating disorders like bulemia and anorexia? Possibly. But, as stated by the National Task Force on the Prevention and Treatment of Obesity states:

"Concerns that dieting induces eating disorders or other psychological dysfunction in overweight and obese adults are generally not supported by empirical studies. Such concerns should not preclude [my emphasis] attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain." (Reference 2)

They deride new medical studies that purpose to show that obesity causes this or that as pseudoscience and - this is the part I find most offensive - that this study is solely to line the pockets of doctors, drug companies and the health industry which is preying on the unsuspecting overweight public.This sort of "militancy and activism" that stops being helpful and is clearly harmful. The "bible" for this organization appears to be "The Obesity Myth" written, apparently, by a lawyer, no less. In the book, the author "demystifies" scientific evidence and medical studies that report obesity is unhealthy. He now travels the country lecturing at obesity-advocacy groups, in my opinion, to tell them "being obese is really OK" and its all the medical community's fault that we are told to lose weight for a healthier life.

Editorial rant follows: From the reviews I have read, the author puts forth some rather unusual tenets in his book. According to one reviewer, the author offers that "One of the most intriguing insights has to do with the fear of fat coming from the white upper class using this as biased ignorance and hatred towards the poorer underclasses." Another, even more mind-bending conclusion was "the modern fear of fat fueled the impeachment of Bill Clinton." Now, I have not, and do not intend to, read this book. But, if these are actually observations that one would take away from reading it, I am not sure I will miss much "insight." By the way, a predecessor book that first espoused the consipracy theory of the "diet mafia" was "Losing It: America's Obsession With Weight and the Industry That Feeds on It" by Laura Fraser. One should know, that Ms. Fraser seems to be a very angry ex-bulemic. She is known to be an ex-bulemic; as to whether she is "angry" or not, I will leave that up to the readers of her book. The point is there is nothing new under the sun. Rhetoric and anger directed against size discrimination is understandable. Debate as to whether obesity is a health risk or not is a little silly. End of editorial.

Are overweight people discriminated against in our society? Absolutely. Do they get passed over for promotions at work simply because they are overweight? Yes, frequently. Do they get refused reenlistment in the military after 18 years of service because they do not meet arbitrary military weight standards? Yes, I have seen it happen, myself. Are they socially stigmatized by clothing stores, airlines, and the advertising media? They certainly are. [Quick! Think about the last commercial you saw and count the number of overweight people in the ad. How many were there? Ever see an overweight person in an advertisement for Taco Bell or McDonald's? Didn't think so.] Do they get looks of disdain in social situations from "skinny" people? You bet your life they do. Do they need organizations to defend their interests if this discrimination is institutionally and infringes on the overweight people? Unfortunately, yes, they do. Do obese children get unmercifully taunted by other children? Yep, and it's been proven in research that children accept obesity less than children with no arm or in a wheelchair.

By the way, for an absolutely dead-on editorial on the obesity problem and where fault should lie, please read this wonderful piece from Morgan Downey, Executive Director of the American Obesity Association. It states, in a much more eloquent way than I could, my personal feelings on the subject of obesity. It is not a "choice;" it's a multifactorial disease!

Now, I certainly understand the psychology of groups who feel under attack and discriminated against within a society. These groups, throughout history, have banded together to protect the rights (and, sometimes, the lives) of the group. They have, often times, been sorely needed support for stigmatized minorities. The Mormons even founded a city for their group. But is it productive to sit and sermonize about how the medical and pharmaceutical industries - as bigfatblog.com members refer to them, the "diet mafia" - are making up research studies for the ultimate goal of causing fear in the overweight patient so they will keep seeing their doctor and taking unnecessary medicine? I just don't think so. Do the FDA, the Center for Disease Control, the U.S. Department of Agriculture (USDA), the American Heart Association, and the American Dietetics Association sit around and discuss how they can invent yet another study to make obese people feel scared so that they will spend more of their hard-earned money on healthier lifestyle, more nutritious eating and regular exercise? I am personally convinced they don't. And, for pity's sake, is the World Health Organization on the take also? Were they plotting against overweight people when they declared, in 1997 (1), that obesity is a worldwide disease epidemic that poses a serious threat to public health? It just doesn't make sense to me.

We certainly need better studies on the causes and treatment of obesity. We need long-term studies to evaluate and identify those people at highest risk from obesity. Certainly, some people, and I tend to believe it is a minority, do live to be a ripe old age and, coincidently, are significantly obese. We need to find out what protects this subgroup of the growing population of obese people from the expected consequences of obesity. We need drug companies to get past the negative economic consequences of the "fen-phen" debacle and get back to work on developing safer and better drugs for the treatment of obesity. We need the government health agencies to work harder on public education of this spreading epidemic.

We absolutely need more understanding and acceptance from our culture on what is a healthy weight. Is it healthy (or even desirable) for all women to look like Calista Flockhart or Gweneth Paltrow or for all men to look like Brad Pitt or Harrison Ford? No, absolutely not. We need to accept, as a culture and as a society, that obesity does not make a human any less valuable, intelligent, or productive. Do we give disapproving looks or look away from people who have hypertension or diabetes? Do we attribute their problem to being lazy or glutinous or poor self-control? What about airlines that ask overweight passengers to buy two seats because of their width and do nothing about the 6 foot 10 inch guy who travels on the airplane with his knees firmly planted into the back of your seat the whole flight? This, my readers, is discrimination at its very worst. Obesity does not correlate with overeating, self-control, cleanliness, personal hygiene, laziness, or I.Q. It is a complex medical condition with many different causative factors that vary from one individual to another. Being skinny does not mean being beautiful or desirable or more productive or more talented. I heard one author, whose writings I do not necessarily agree with, state one thing very well when he said "asking everyone to weigh the same is like asking every person to be taller." People do, thank God, vary in height, weight, and all the other factors that make someone an individual. Some write that we are becoming too accepting of obesity in our culture and it might become a lifestyle that will cost us billions in health care costs and early death. To these misguided people, I refer them to an editorial from the previously-mentioned AOA.

But, this is a far cry from saying that it is healthy to be obese. I personally think a person should not focus on weighing a certain number on the scale. I, as do all physcians,believe my patients should focus on living the healthiest lifestyle they can with the ultimate goal of living the longest, healthiest life possible. What they eventually weigh when they have achieved this lifestyle is irrelevant. But, NAAFA posits that people can be "naturally fat." To whit, I offer this quote from their web site:

"If you've been fat for most of your life and several other family members are also fat, the odds are that your natural body size is larger than average. Children with one large parent have a 40% chance of being large, and children of two fat parents have an 80% chance of being that size also. Current setpoint theory states that everyone has a natural weight which their body will automatically protect. Diets are nothing but voluntary starvation. The body protects itself from perceived famine by increasing energy efficiency and raising its set-point even higher. This theory explains why diets more frequently result in weight gain than in permanent weight loss."

And this pearl of self-defeating wisdom: "You have about as much chance of winning the lottery as you do of permanently losing weight by dieting." With the medical information available, in my opinion, this is not rational thought.

Final point: Is it possible to be "fit but fat?" My answer is yes. Are they people with a body mass index of 35 or 40 who can run circles around me on a treadmill? Yes, probably thousands. Are there obese men who are going to live longer, more productive and happier lives than me? You can buy a lottery ticket with those odds. Are there obese males over 50 who have more money, better sex lives, better careers, more talent, better blood pressures...better anything, than me? Yes, again, probably thousands, maybe tens of thousands. My only question is: "If these men weighed less, would they be even healthier? I personally believe they probably would. And, it is because of that belief that I will continue to help direct obese patients I treat to pursue and strive for a healthier lifestyle. Maybe 10 or 20 years from now, longtitudinal studies will show me to have been wrong all along. I, quite honestly, hope so. But, that's a lottery I wouldn't buy a ticket to win.

By the way, in the interest of promoting balanced information, if you are interested in the opposite viewpoint, you should checkout "BigFatBlog.com." It is a "web log" (the origin of the term "blog") - a running series of messages - that discuss issues related to obesity and its treatment (or lack thereof). They are an active, vocal group and their site is full of interesting (if, in my opinion, somewhat misled) commentary. Their views are in direct opposition to mine but they are as passionate and feel as strongly about their opinions as I do about mine.

2. Dieting and the Development of Eating Disorders in Overweight and Obese Adults, Arch Int Med 2000; 160:2581-2589.