Yesterday I wrote about how the mostly minimal or non-existent or indeed inverse relationship between “overweight” and “obesity” on the one hand, and risk for severe COVID outcomes on the other, has, perversely enough, occasioned yet another outburst of moral panic from people claiming that the real problem is that Americans are fat and we must Do Something about that.
Here I want to just make a few more general observations about how a moral panic that high weight is a massive public health crisis in America continues to dominate public health discourse, in the face of all evidence to the contrary.
I’m going to list some basic points emphasized by the growing number of critics of that panic, both inside and beyond the academy, along with the stock responses to these points generated by the Weight Loss Industrial Complex:
Critics: BMI is a garbage metric for individual diagnostic purposes, and of very limited usefulness at even a population-wide level, except perhaps at real statistical extremes.
WLIC: Yeah that’s pretty much true, but we never said that it was anything but a very rough and ready measurement, not some sort of rigorous scientific tool or anything.
Critics: Then what kind of sense does it make to just declare that everybody who has a BMI of 25 is “overweight,” and that everybody who has a BMI of 30 has a literal disease? This is the official position of the American public health establishment by the way.
WLIC: Well that’s just science.
Critics: Your two responses seem to contradict each other on their face.
WLIC: Are you saying that morbid obesity isn’t a public health problem? Have you even been to Wal-Mart lately?
Critics: Not only are your definitions based on what you acknowledge is a garbage metric, they are massively over-inclusive when it comes to even the most basic observational correlations between weight and health. The entire “overweight” range (BMI 25-29.9), which currently includes nearly one third of Americans, features overall health outcomes that are as good or better than the “healthy” weight range, and it’s difficult to find any significant negative overall health correlations for people “with” Class I obesity (BMI 30-34.9) as well, even though most Americans who are “obese” are in this category.
What exactly is your rationale for pathologizing an enormously broad weight range, that currently includes the majority of adult Americans, but lacks even the beginnings of a crude observational justification, let alone any kind of clinical demonstration of causal links?
WLIC: Are you saying that morbid obesity isn’t a problem? Do you think it’s really OK to have a BMI of 50?
Critics: The rationale for making purportedly excess weight levels a target of public health intermediation is that such initiatives will reduce rates of “overweight” and “obesity.” All your initiatives to this point have been complete and utter failures in this regard. Does this suggest that your methods may be unsound?
WLIC: We must kill them. We must incinerate them. Pig after pig, cow after cow, Burger King after Burger King, Krispy Kreme after Krispy Kreme.
Critics: Are you ever going to answer any of our questions?
This is a parody, but not a very gross one. It’s truly remarkable how everyone more or less acknowledges that BMI is a largely useless measure, yet how this acknowledgment has no effect whatsoever on such absurd public health policies as categorizing everyone with a BMI of 30 as having a disease, with the definition of the disease in question having literally no parameters other than having a BMI of 30.
(BTW the common criticism of BMI is that it doesn’t measuring body fat per se assumes implicitly that there’s some sort of medical consensus about what percentage of body fat is healthy, when in fact there is no such consensus, given that the available evidence indicates that what might constitute a healthy level of body fat for any particular individual varies enormously, depending on age, gender, ethnicity, overall body composition, visceral versus subcutaneous fat etc. etc.).
In a similar vein, the constant attempt to shift the focus of discussion from “overweight” and “obesity” in general to the very fattest Americans (so-called morbid obesity, i.e., BMI 40+) is a product not only of the fact, referenced above, that even in the crudest statistical sense the definitions of what constitutes weighing too much are wildly over-inclusive, but also of the sort of psychological triggering words like “overweight,” “obesity,” and “fat” have in a hysterically fatphobic culture. (A loose analogy here would be if it were the case that marijuana was a completely innocuous or mildly beneficial drug, but every time someone argued for its legalization the response would be “so you think there’s no problem with being a meth addict?”)
Basically discussions of this subject automatically conjure up visions of people who weigh 500 pounds, analogous to the way that the phrase “young black male” conjures up visions of the Crips and the Bloods for the average Fox News viewer. This is why people are so often shocked when they discover that they are “overweight” or “obese,” according to the official definitions of Science of course, when they don’t consider themselves fat in any meaningful sense (The reverse phenomenon, whereby plenty of, to generalize loosely, upper class white women with BMIs of 24 do consider themselves fat, and are desperate to get ahold of dangerous diet drugs to make themselves thinner, is also very much a problem).
Underlying all these discussions is the indisputable fact that as a matter of social policy we have no idea how to make fat people thin, or to keep people from getting fat in the first place (60 years ago 45% of the American adult population was “overweight” or “obese” per today’s definitions of those terms, at a time when food scarcity was much more widespread than it is today).
All this would seem to argue for harm reduction strategies that would, as a matter of public health, not categorize people in terms of whether they can maintain or achieve supposedly “healthy” weights, and would certainly avoid claiming that 42% of the American population currently has a disease, with the disease simply being having a BMI of 30 or above.
I acknowledge that not all the public health concerns about weight in America are wholly bogus. I do for example think it’s a legitimate public health concern that the percentage of Americans with BMIs of 40 or above has increased from 2.8% to 8.3% over the past 30 years. I don’t think that telling those people that it’s bad to be fat is a helpful response to that development however, as I’m pretty sure they’re getting that message 24/7 from the culture as a whole.
But the overwhelming majority of public health discourse about fat in America, just like the cultural discourse in general about the subject, isn’t driven by any sort of real health concerns at all, but rather by three other factors: aesthetic disgust toward fat — or “fat” — bodies, class anxieties about how fatness is associated with lower class status and downward mobility (as always in America this sort of anxiety has a strong racial component as well), and the financial interests of the WLIC.
The latter seeks constantly to monetize that disgust and anxiety by medicalizing it, thereby laundering aesthetic disgust and class/race anxiety into concerns about health, and thus making those purported concerns a valid basis for authorizing third-party payments for the various useless or worse treatments for this “disease” that it’s constantly proffering to the American public.