Early in my new novel, Big Brother, the narrator meets her older brother at the airport and initially fails to recognize him: he’s gained hundreds of pounds.
“What happened to Uncle Edison?” her stepdaughter asks quietly the first night of the brother’s visit. “Is he sick?”
“According to the latest thinking on the subject,” the narrator replies, “yes.” She notes, “Though I was personally unsure how labeling obesity an ‘illness’ got anyone anywhere.” Now it’s official—the American Medical Association has classified obesity as a disease—but it’s still not clear this gets anyone anywhere.
My older brother was morbidly obese. His case history exemplifies the difficulty of determining whether obesity is a disease or is merely a risk factor for diseases. After a cascade of medical crises, he landed in the hospital after carbon dioxide poisoning from sleep apnea (aggravated by his weight). He caught an infection, which his struggling circulatory system had a hard time fighting off. Technically, he died from cardiac arrest—his heart having been weakened from pumping for years against that poundage. He may have died because of obesity, but he didn’t die of obesity. Does it matter?
In principle, I resist semantic solutions to real problems. Switching labels is cheap and changes nothing. (Training people to eschew the word retarded doesn’t make them treat the mentally disabled any better.) But this ruling may have social repercussions that go beyond terminology.
You can bring disease on yourself, of course, like smoking-related lung cancer. Yet designating a state of being as an illness has a subtle distancing effect. It gently suggests that this turn of events is due either to outside forces or to weaknesses inherent in the body that are beyond your control. The AMA’s deeming alcoholism a disease in 1956 has encouraged some alcoholics to embrace Alcoholics Anonymous’ total abstinence and to recite at meetings, “I am an alcoholic,” not “I was.” For alcoholism is apparently not something you get rid of but something you have.
If the AMA’s ruling encourages insurance companies to cover bariatric surgery, swell. But there is no perfect cure, and the one enduringly effective therapy out there is the exercise of personal responsibility. (No, I will not buy potato chips.) Medicalizing the condition actually undermines personal responsibility by turning something you get rid of into something you chronically have. And even then, the overweight cannot embrace the alcoholic’s total abstinence. We all have to eat, and so, barring removing part of your stomach, we all have to make choices about what and how much.
At the same time, the word disease is also unambiguously negative. Thus this AMA decision pushes back against the growing movement that maintains we can be “healthy at any size.” It defies the big-is-beautiful lobby, which sees “fat-ism” at the last acceptable prejudice and as the imposition of a subjective, arbitrary, literally narrow aesthetic in the deceitful guise of concern for health (a credible charge, actually). The AMA has spoken loud and clear: beyond a certain point, carrying large amounts of weight, as Webster’s defines diseases, “impairs normal functioning.” The AMA is therefore guilty of—a phrase I find mysteriously grating—fat shaming.
Since most clinicians don’t think that getting very fat is a health-neutral lifestyle choice, perhaps the AMA’s identifying obesity uncontrovertibly as a problem is for the best. A host of theories now try to explain the worldwide expansion of the waistline, many dovetailing nicely with the disease paradigm: that it is caused by one or more viruses, genetic predisposition, chemicals in the environment, the transformation of the gut microbiome or a marijuana-like acid in seed oils like soy and corn. But we have scads of theories and very few solutions to go with them. Currently, there are no medical cures that improve on willpower. Until there are, it’s best if folks continue to regard obesity as something they can redress, not as something they have.