[This essay was published in the May 2015 issue of San Francisco Medicine. The entire issue is devoted to obesity and you may find it on-line here. ]
A war on obesity has been declared. Public health authorities have identified excess body mass as an epidemic threat. With a great sense of urgency, they are mobilizing resources to address this preeminent health concern. To bolster the effort, the American Medical Association has recently decreed obesity as a disease. Local, state, and national political powers are now engaged in its eradication and have enlisted the assistance of a number of celebrities.
But does the war on obesity have clear objectives and a sound strategy? Will the campaign be conducted as a targeted strike with a well-defined exit plan, or will it turn into an open-ended conflict with limited prospects for victory? Will the offensive conform to “just war” principles, or will it be mired in moral confusion? Whatever the answers, I have reasons to object to this war.
To begin with, the means by which the campaign against obesity identifies the enemy is questionable. The current definition of obesity—a body mass index (BMI) above an arbitrary cut-off point—does not amount to a compelling description of a disease. According to this definition, obesity does not entail having symptoms but only a statistical risk of future complications. Individuals on either side of the cut-off point cannot be distinguished in a clinically meaningful way, yet one will be a target for intervention while the other may be falsely reassured of being safe.
Furthermore, the enemy is not identified on the basis of sound pathological science. Seen under the microscope, the fat cell from an obese individual cannot be distinguished from the fat cell of a slender person. Metabolic, hormonal, or behavioral criteria to segregate the obese from the non-obese have so far proven elusive. More important, the foe in the war on obesity cannot be separated from the friend. Unlike infectious agents or cancerous growths, fat tissue and body weight are intrinsically constitutive of the individual. An increase or a decrease in my mass is necessarily—at some level—an increase or a decrease in me. The war on obesity, then, could easily degenerate into a war on the obese.
To side step these difficulties, commanding officers in this conflict have targeted their action against soda drinks, corn syrup, and other carriers of empty calories. Unfortunately, the same public health authorities had also warned for many decades against other dietary components, namely, saturated fats and cholesterol. That advice seemed sound at the time, but has lately been called into question by the scientific community. What’s more, according to some experts, the war on dietary fat may have prompted a population-wide increase in the consumption of carbohydrates, setting in motion the current obesity epidemic. The credibility of dietary guidelines is thus diminished, and a major weapon in the war on obesity is therefore seriously impaired.
Finally, the threat posed by excess body mass may not be as ominous as initially calculated. For example, while the number of obese Americans has increased since the early 1980’s, cardiovascular mortality has decreased and, in recent years, has even plummeted. In the last 10 years, cardiologists have also identified an “obesity paradox:” when it comes to heart failure, myocardial infarction, and recovery from bypass surgery, a BMI above what is considered healthy can actually improve survival.
Proponents of the war on obesity still believe the campaign against the BMI will encourage a healthier attitude among the people. But while some individuals may respond positively, others may not. To conflate the idea of health with a single morphometric measurement is a gross oversimplification that can cause excessive anxiety, impair self-image, or provoke eating disorders. Serious collateral damage seems inevitable.
My critical judgment against the war on obesity is not meant to trivialize the condition. Nor do I deny that obese persons are at risk of serious complications. But obesity is among the most intimate of diseases. It should not be addressed with propaganda and methods of war. It calls, instead, for a language of friendship and genuine care.