August 1, 2023
SINGAPORE – The stigma that surrounds people living in larger bodies is pervasive and deeply affects the people it is directed at. It has been described as one of the last acceptable forms of discrimination.
Some researchers think the term “obesity” itself is part of the problem, and are calling for a name change to reduce stigma. They are proposing “adipose-based chronic disease” or “adiposity-based chronic disease” instead.
We study the stigma that surrounds obesity – around the time of pregnancy, among health professionals and health students, and in public health – more widely. Here is what is really needed to reduce weight stigma.
Weight stigma is common
Up to 42 per cent of adults living in larger bodies experience weight stigma. This is when others have negative beliefs, attitudes, assumptions and judgments towards them, unfairly viewing them as lazy, and lacking in willpower or self-discipline.
People in larger bodies experience discrimination in many areas, including the workplace, intimate and family relationships, education, healthcare and the media.
Weight stigma is associated with harms including increased levels of cortisol (the main stress hormone in the body), negative body image, increased weight gain and poor mental health. It leads to decreased uptake of, and quality of, healthcare.
Weight stigma may even pose a greater threat to someone’s health than increasing body size.
Should we rename obesity?
Calls to remove or rename health conditions or identifications to reduce stigma are not new. For example, in the 1950s, homosexuality was classed as a “sociopathic personality disturbance”. Following many years of protests and activism, the term and condition were removed from the globally recognised classification of mental health disorders.
In recent weeks, European researchers have renamed non-alcoholic fatty liver disease “metabolic dysfunction-associated steatotic liver disease”. This occurred after up to 66 per cent of healthcare professionals surveyed felt the terms “non-alcoholic” and “fatty” to be stigmatising.
Perhaps it is finally time to follow suit and rename obesity. But is “adiposity-based chronic disease” the answer?
Beyond BMI
There are two common ways people view obesity.
First, most people use the term for people with a body mass index (BMI) of 30kg per metre squared, or above. Most, if not all, public health organisations also use BMI to categorise obesity and make assumptions about health.
However, BMI alone is not enough to accurately summarise someone’s health. It does not account for muscle mass and does not provide information about the distribution of body weight or adipose tissue (body fat). A high BMI can occur without biological indicators of poor health.
Second, obesity is sometimes used to describe the condition of excess weight when mainly accompanied by metabolic abnormalities.
To simplify, this reflects how the body has adapted to the environment in a way that makes it more susceptible to health risks, with excess weight a by-product of this.
Renaming obesity “adiposity-based chronic disease” acknowledges the chronic metabolic dysfunction associated with what we currently term obesity. It also avoids labelling people purely by body size.
Is obesity a disease anyway?
“Adiposity-based chronic disease” is an acknowledgement of a disease state. Yet there is still no universal consensus on whether obesity is a disease. Nor is there clear agreement on the definition of “disease”.
People who take a biological-dysfunction approach to disease argue that dysfunction occurs when physiological or psychological systems do not do what they are supposed to.
By this definition, obesity may not be classified as a disease until after harm from the additional weight occurs. That is because the excess weight itself may not initially be harmful.
Even if we do categorise obesity as a disease, there may still be value in renaming it.
Renaming obesity may improve public understanding that while it is often associated with an increase in BMI, the increased BMI itself is not the disease. This change could move the focus from obesity and body size to a more nuanced understanding and discussion of the associated biological, environmental and lifestyle factors.
Before deciding to rename obesity, we need discussions between obesity and stigma experts, healthcare professionals, members of the public and, crucially, people living with obesity.
Such discussions can ensure that robust evidence informs any future decisions and proposed new terms are not also stigmatising.
What else can we do?
Even then, renaming obesity may not be enough to reduce the stigma.
Our constant exposure to the socially defined and acceptable idealisation of smaller bodies (the “thin ideal”) and the pervasiveness of weight stigma means this stigma is deeply ingrained at a societal level.
Perhaps true reductions in obesity stigma may come only from a societal shift – away from the focus on the “thin ideal” to one that acknowledges health and well-being can occur in a range of body sizes.
Ravisha Jayawickrama is a PhD candidate at the School of Population Health in Curtin University in Perth, Australia. Blake Lawrence is a lecturer at the same school. Briony Hill is deputy head of the Health and Social Care Unit and a senior research fellow at Monash University in Melbourne, Australia. This article was first published in The Conversation.