Obesity bias needs to end

I have witnessed a lot of obesity bias in my career, and I have railed against it on more than one occasion. But it’s not the focus of my career, as it is for some of my colleagues. I have long thought those colleagues who do devote themselves to the topic may tend to overlook a very fundamental question, namely: Why would obesity bias even exist? What rational basis is there for people — any people — to be biased against other people because of adipose tissue?

To me, this question is important — because while we may not fix problems we do understand, we almost never fix problems we don’t understand. If we are to banish obesity bias, among doctors or any other group, we need to know it at its origins. We need to get to bedrock.

In general, the bedrock for explaining human behavior is evolutionary biology. Modern culture may refract the imperatives of biology, but they tend to persist, if in new guise. In biology, for instance, food tends to be the currency of survival, and so modern culture has conflated currency and food: We make dough, win bread, and bring home the bacon.

I believe obesity bias has origins in evolutionary biology as well, related directly to the one great imperative of our selfish genes: survival. Survival, in turn, depends greatly on food and sex. And so it is that this is a story about sex and food. Let’s start with sex.

All other things being equal, females tend to prefer strong, well-muscled males. This is true of human females, but extends to most mammals, and other animal classes as well. And it makes perfect sense. In a natural world, strong males are likely to do a better job of securing food, and defending hearth and home. Females, and their genes, would tend to favor males, and male genes, associated with vigor and strength that foster the family unit’s survival, and thus the propagation of the very genes that favored this scenario in the first place.

Of course, modern culture does indeed refract this. In cultural context, wealth and power not mediated by muscle may substitute for the more primitive form of vitality. Men may benefit from this, and the relevant research suggests that obesity bias and its consequences disproportionately encumber women.

Across human cultures, males tend to favor females not of any given size, but with certain proportions. In cultural context, those proportions have been dressed up with all the mystique of sex. But they are really a visual cue about probable reproductive success. Just as females tend to favor males who look like they can put bread (or mammoth) on the table, males tend to favor females who look like they can deliver, and nurture, babies. The famous male fascination with breasts is really a message from survival-driven genes about the likelihood of well-fed offspring.

And since we are very visual creatures, these messages about sex and survival are mediated to us principally by our eyes. If we were more dependent on scent, or sound, we might be less influenced by body shape and size, and more motivated by other factors. But this, too, is part of our biology, and so it is the visual cues that predominate.

So here we have point one: There are almost certainly prevailing preferences for certain standards of physical appearance that are hardwired into us all, because they have long related to reproductive success. This doesn’t make them right, or good — but it does make them real and important. We are not likely to be masters of our behaviors when we ignore the reasons for them.

That’s the sex story; what about food? Here I am less confident, and acknowledge that while I write with professional credentials on the obesity topic, I am only a very amateur anthropologist. I have read a lot of anthropology, but don’t have credentials. I would appreciate the impressions of any real experts who happen upon this.

Body fat is a form of energy storage. The safest, most reliable place to put a surplus of calories today against the advent of a rainy day tomorrow is inside your own skin, so you can take it with you wherever you go. In the context of evolutionary biology, the reason our bodies can and do grow adipose tissue is because the capacity to store excess food reserves today to weather tomorrow’s famine favored survival.

In a world where calories are a rate-limiting commodity in the struggle to survive, as they were throughout most of human history, it might be that you and I are to some extent competing to get enough. And if you manage to grow adipose tissue, it might increase the risks of me not getting enough calories to survive. Maybe obesity evokes some antipathy because it threatens us. Maybe in native context it hints at someone getting more than their fair share, and putting the rest of us at risk of starving. This is just conjecture on my part, admittedly — but it certainly makes sense.

And then lastly, in terms of basic biological impulses, there is our innate xenophobia. Xenophobia is a pretty deplorable tendency, as it accounts for many of the horrible abuses human beings have perpetrated on other human beings who looked different. We have done this because of skin pigment. We have done this because of facial features. It redounds to our great shame, but it, too, makes sense in basic biological context.

Throughout the long sweep of human prehistory, we lived in small and widely-dispersed groups. Members of our own group worked with us and fostered our survival. Members of any other group might try to take from us, and profit at our expense. Familiarity meant safety; foreign meant dangerous. And since obesity has been rare throughout most of human history, maybe it still evokes the foreign, and taps into some subconscious aversion, borne of fear.

These are potential sources of obesity bias in the population at large. What of doctors specifically?

Well for one thing, doctors are just people, and so are prone to all the same foibles as everyone else. But I think these are compounded by frustrated impatience, and lack of self-efficacy. Doctors, after all, are trained to fix what’s broken. When hearts stop, we restart them. When wounds bleed, we suture them closed. When bones break, we set them. When tumors grow, we cut them out.

But we are not very good at fixing obesity, which is of course far more a cultural than a clinical problem. Not being able to fix what you are supposed to fix does not tend to bring out the best in people. In the case of doctors, this is by no means limited to obesity. Anyone with a “syndrome” has likely encountered this same brand of frustrated intolerance. In medicine, if we understand and truly respect a condition, it gets promoted to a “disease.” If we don’t understand, and aren’t entirely committed to respecting it, it languishes as a syndrome. In my 20 years of clinical experience, patients with syndromes, and patients with obesity, have reported pretty comparably unpleasant experiences.

So much, then, for the nature of the problem. What of the solutions?

For doctors, it begins in the training process. We can, and should, make it clear in every variation on the theme of medical education that obesity bias is wrong, unjustified, and impermissible. We need doctors and doctors-to-be, and all other health professionals for that matter, to understand the culture-wide origins of epidemic obesity, and the limits of personal control over it. We also need to train health professionals to help patients manage their weight so there is a better option than frustrated intolerance.

And here, I am not just opining; I have put years of effort where these words are. I am currently writing the third edition of a nutrition textbook for health professionals with dedicated chapters on weight management and counseling. And my colleagues and I have developed, and offer free of charge, an online training program in constructive, compassionate lifestyle and weight-control counseling that carries with it four hours of category one continuing medical education credit from Yale University, at no cost. To my colleagues reading this: Please help yourselves!

But the best means of fixing obesity bias among doctors is fixing it everywhere, banishing it from our culture. This bias is wrong, unfounded, and counterproductive. Our society has tolerated it openly, and sanctioned it tacitly, for too long already.

If my arguments above are sound, then fixing obesity bias requires replacing mindless imperatives coded into our genes with thoughtful products of our culture. Richard Dawkins, arguably the father of modern thinking in evolutionary biology, makes the case for just this kind of substitution in his groundbreaking book The Selfish Gene. Genes are bequeathed to us by biology, blind to all but survival. But memes, units of cultural transmission, are of our devising. We can decide which matter, and propagate them accordingly.

Obesity bias needs to be fixed. We are most likely to fix it when standing on a solid bedrock of understanding it at its origins. We can then replace the crude and obsolete survival-related imperatives bestowed to us in our genes, with the better angels of our nature, borne of culture, mediated by memes. If not us, who; and if not today, when better?

David L. Katz is the founding director, Yale-Griffin Prevention Research Center

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  • http://twitter.com/DDrakeMD DDrakeMD

    Obesity is a signal of poor health. It’s a primal repulsion. Furthermore, the predominant paradigm is that people just “can’t control themselves” and ergo are fat. We are disgusted by lack of discipline.

    It makes sense that “lack of control” theory reigns, because the only way to fix obesity is by tremendous control and repression of the drive to eat. Few overcome it in the long term.

    As a formerly obese person and a physician, I can speak with good authority on this issue. Almost all doctors are disgusted by obese patients. That’s not going to end until we shift our paradigms.

    • adh1729

      “the only way to fix obesity is by tremendous control and repression of the drive to eat”: is that truly so? Or is it a matter of making healthy food choices (e.g. eat vegetables, avoid processed food, sweets, soda pop)?
      I have never been obese, so I can’t speak from personal experience, but it seems to me that obesity has become a significant problem only in the last few decades, coinciding precisely with the rise of the processed and fast food industries, and factory farming. I don’t think that availability of food and calories, per se, is the issue. Food was around in 1950 aplenty.

      • Guest

        Agree completely. More than overeating I blame the types of foods we eat along with a sedentary lifestyle. I think in the 1950s a middle class family could live comfortably on one income and own a home, car, and take vacations. Now, families struggle to make it on 2 incomes and work day and night to make ends meet. How are they going to make positive diet choices and find time to exercise?

        • Guest

          Most Americans “find time” to watch at least 30-60 minutes of TV a day. Throw out the boob tube and spend that time having a nice walk around the neighborhood instead. That’s a start.

          • Guest

            I’m not making excuses for anyone in particular, but I can see how people can become obese without even trying in today’s society.

            FYI, walking around the neighborhood when you live in a high crime area is not the greatest suggestion either.

            There are loads of social and financial factors that can contribute to obesity. Telling someone without transportation or close access to a market to make better food choices might not yield great results. Telling someone to walk around their blighted neighborhood for exercise might not be ideal either.

            What’s the solution? The end of subsidizing cheap crappy food and the start of subsidizing produce and fresh food. If we can empower and enable people to make good food choices we might have a chance.

          • Guest

            “The end of subsidizing cheap crappy food and the start of subsidizing produce and fresh food.”

            There are already nearly 47 million Americans for whom we ARE subsidizing food, via Food Stamps. And Food Stamp recipients tend to be fatter.

            So let’s start by mandating that anyone receiving Food Stamps attend nutrition & home economics classes, and then ban them from using their food stamps on anything but healthy food.

            Instead of giving them MORE money, make them spend the money we already give them more wisely.

          • Guest

            “FYI, walking around the neighborhood when you live in a high crime area is not the greatest suggestion either.”

            So turn off your TV and do jumping jacks and situps on your living room floor. FFS, it’s not MY fault that fat lazy people eat too much and can’t be bothered getting off their butts. If you want to “fix it” via government mandate, mandate that fat people are not allowed to have TVs, and must take part in monitored exercise programs 3 per week. Put an electronic ankle bracelet on them that will shock them if they haven’t got off their butts and raised their heartbeat into exercise level for over x number of hours.

            If you’re going to demand that I pick up the tab for fatties, I get to have some say in how they live their lives.

          • Guest

            Who the hell said anything about a government mandate? You’re already subsidizing unhealthy food production (corn subsidies, anyone?). Why not subsidize fruits and vegetables instead? Probably because that industry doesn’t have as powerful a lobby as does corn.
            Also, you might want to end the anger and stop blaming the sick for being sick. If you are a physician (the level of rage suggests to me that you are) realize that these people are the reason you have a job in the first place.

          • Trev

            “Put an electronic ankle bracelet on them that will shock them if they haven’t got off their butts and raised their heartbeat into exercise level for over x number of hours.”

            Good grief.

          • http://twitter.com/VanessaObRN VanessaObRN

            I think they already do that at those very expensive fat farms where they guarantee the client will lose weight or get their money back.

      • Guest

        The problem is overindulgence, and laziness, and the mandated “acceptance” of fat people.

  • Ratherbesurfing

    Musings on the evolutionary origins of “obesity bias” make for entertaining speculation. If bias is truly “hard wired” into to us as you suggest it will be futile to try to change that. Bias is a term that has such negative connotations. Why should we as physicians want to rid ourselves of this bias? Bias is simply an opinion on the relative merits of one thing versus another. Bias against obesity is simply the realization that it is unhealthy and undesirable in our patients. Bias is what spurs us into changing course and habits. If you weren’t biased against obesity, what be the point of counseling on weight management and writing a book on nutrition?

    • Nils

      The next thing we know, cardiologists will be damned for being “biased” against patients with heart disease who refuse to moderate their salt intake. It will be akin to bigotry to dare put a patient with CHF on a low sodium diet, everyone should feel free to do whatever they want, eat whatever they want, no matter how harmful, and to suggest otherwise is just hateful and cruel. Here Mr Jones, have another bag of yummy salty potato chips!.

    • Faxon

      The writer is using the word “bias” in the sense of bigotry and prejudice. I think you probably understand this but pretend not to in order to justify your predudice against fat folks. Do you have “bias” against cancer? Do you have “bias” against broken legs? If a fat person enters your office and you immediately have disgust towards them, do you really believe this will not impact your treatment of them for the worse? You say- it is futile to change something that is “hard-wired.” You are conveniently ignoring our ability as individuals and as a culture to develop more compassionate ways of treating each other. Your lack of compassion for your patients, and lack of open-mindedness about the causes of obesity is unsettling in a doctor.

      • Trey

        “Do you have “bias” against cancer?”

        Do you have ‘bias’ against a heavy drinker with cirrhosis who refuses to cut down on alcohol consumption?

        Do you have ‘bias’ against a three pack a day smoker with lung cancer who refuses to quit smoking?

        • Faxon

          I do not understand why someone must have prejudice, revulsion, or disgust against another in order to help them with an addiction or compulsion. I am not in favor of “fat acceptance”. Or smoking. I am in favor of all of us being less judgmental of each other. For example, calling alcoholism a disease does not, IMO, get the drinker off the hook for working on the disease- stopping drinking. But do we need to be disgusted with alcoholics? Does that help sober them up?

          • Guest

            The word “bias” does not mean what you’re pretending it means.

  • Guest

    “Obesity bias needs to end”

    Bias against smokers needs to end.

    • PA

      Treating anyone whose own actions have injured them, yet they refuse to stop doing what got them sick in the first place, can be a little frustrating. Whether it’s a patient with COPD who continues to smoke two packs a day, or one with multiple obesity-related morbidities like diabetes, hypertension, heart disease and sleep apnea who refuses to moderate their eating or start doing some exercise. Or a cirrhotic alcoholic who keeps drinking even as he’s having ascites drained regularly. It would be hard to honestly say I have no bias at all, at least internally, against such patients as opposed to those who are sick through no fault of their own. But still you don’t let that show, you just do what you can. No point being openly judgmental, you’ll just chase them away and then they won’t get ANY treatment and you’ll have that on your conscience, that you effectively harmed someone you were bound by oath to help.

    • Guest

      Some pathologically self-destructive behaviors are more equal than others.

  • http://www.abicana.com/ Knut Holt

    To put it bluntly: Most medical professionals are themselves obese, and tragically enough especially pediatricians. I have seen more bias towards healthyweighted people than obese ones from the medical profession. The obesity bias talked about here, must be a bias toawrds the very extreme obese persons, not towards common obesity, which can be gross enough, though.

  • Payne Hertz

    Many medical professionals have personality disorders, and it makes them feel superior to look down on their patients for any reason they can find. Some of them get off on the pain and distress they cause stigmatizing and vilifying sick people in public forums or in person.

    The good news is that the obese can lose weight, come to accept being overweight or find better doctors; the bad news is personality disorders tend to be incurable.

    • Mengles

      And by “better” doctors you mean those who will make the patient “Feel” good about being obese even though it is killing them.

  • Nils

    “But the best means of fixing obesity bias among doctors is fixing it
    everywhere, banishing it from our culture. Our society has tolerated it openly, and sanctioned it tacitly, for too long already.”

    Yes how do you feel about the way smokers are demonized and discriminated against, shouldn’t we “banish” this “bias” from our culture, since people should be free to engage in harmful and even pathological behavior, no matter the cost to our health system or to society on general, without fear of “bias”?

    • Payne Hertz

      Everyone who fails to live by a standard of 100 percent moral perfection should be denounced and villified. Appropriate punishments must also be found, of course.

      This rule will not be applicable to doctors, who set the standard for moral perfection.

      • Guest

        The way you feel about doctors is the way I feel about politicians.

        I think most docs are nice. But I avoid being a patient as much as possible.

      • Guest

        “Everyone who fails to live by a standard of 100 percent moral perfection should be denounced and villified.”

        No, but if I’m forced to subsidize your health care, I reserve the right to be ticked off that someone’s willfully unhealthy lifestyle is stealing away money that I’d rather spend on my own wife and kids.

        • Payne Hertz

          Don’t be surprised when your wife and kids get sick to hear someone say the same about you.

  • LastoftheZucchiniFlowers

    That we are hard-wired to sniff appreciably towards the Cinnabon scent wafting through the mall (as opposed to the aromatic broccoli steam) is NOT THE ISSUE. It’s been thousands of years since we had to run from tigers so we need to bring our intellect to bear when the lure of fat and sugar as ice cream cone or fried doughnuts triggers olfactory and salivary overdrive. Quite simply we must choose to EAT something ELSE while acknowledging that the Id houses our biological imperative. Isn’t THAT they payoff for being conscious of our behavior and for taking responsibility for every single action we take (food that we choose to eat)?

  • Mike

    “Somebody told me that in South Korea and Japan, it is socially permissible to publicly shame and humiliate an obese person.”

    We do that to smokers in America, I don’t see why we shouldn’t do it to fatties.

    Back when I was younger, there WAS shame in being fat. And we didn’t have nearly so many fat people.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Because it infringes on their right to choose how they want to live their lives.

      • Mengles

        Well if doctors are going to have P4P measures based on their patients obesity then it becomes our problem.

  • Guest

    Normalizing pathological behavior will lead to more pathological behavior.

  • Trev

    I’m pretty sure people who are obese already know they’re obese, they probably don’t need your “help” pointing that out.

    Come on. The world is a mean enough place already, it doesn’t need more gratuitous cruelty and intolerance.

    • Guest

      I agree. Bunch of bullies with anger management issues in here.

  • Guest

    Brilliant! Let’s go out and shame the fat people. Add in there the smokes, the homeless (lazy good for nothings just need to be shamed into getting a job), drug addicts, prostitutes and anyone else we think poorly of and might be costing us more in health care dollars.

    The Japanese diet is probably more of a factor in their lower BMIs than public shaming, don’t you think?

    “Shaming” people into action is a pretty poor way to initiate change. More than likely the person will resent, then avoid you. Have you noticed this happening with your friends and family?

  • Guest

    You don’t say much about a key cause of obesity: eating to sooth emotions we feel powerless to deal with. Because the obese wear their dysfunction so openly, we as a society highlight it. As far as bias goes, I would say we have just as strong a bias against alcoholism, bulimia, gambling, sexual misconduct etc. The main difference is those vices are more difficult to see until the consequences are tragic.
    Helping the obese to deal with their problems is, for the most part, not a medical issue. It is a mental health issue much the same as other addictions. Doctors can’t “fix” obesity. We as culture can support each other as we seek a healthier state of mind, heart and body.

    • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

      Not everyone who has a problem with obesity does so because of lifestyle choices. Some people have medical problems that make it hard for them to lose weight. I so agree with you about that as a culture we can support each other in trying to seek a healthier state of mind, heart, and body. And while I agree with you on this we can’t make anyone do this if they don’t want to. If we were to try and do that like we have heard about some cases around the country where children are being taken from their homes, then you will have people saying that it’s infringing on their right to choose how they want to live their life. We are talking about those that are capable of making such a decision.

  • guest

    Dr. Katz, having read your article, I would like to point out some issues in regards to your argument about the “obesity bias.” If I have misinterpreted your points, I do apologize in advance,

    1. You state that the reason behind our fat storage adaptation is the need to “store excess calories,” and that the reason this was necessary had to do with survival in a “calorie limited world.”

    This view is approximately a half century out of date in regards to both human physiology and anthropology. It is well accepted that hunter-gatherer societies did not have much issue acquiring adequate amounts of food, and indeed are very good at it. Any book on anthropology ought to confirm this view. In addition, since the 1930s and definitely by the 1960s it has been known to most medical researchers that adipose tissue does not act as a “storage” for excess calories, but rather plays a role of maintaining a certain dynamic equilibrium of energy in the body. In other words, your fat tissue acts as a wallet of sorts, where by fatty acids are released and stored based on immediate needs, and not as some kind of storage for starvation.

    2. You state that certain sexual preferences dominate our behavior, and that these preferences can be explained by evolutionary biology.

    Evolution can certainly influence our behavior, however it does not do it in the ways that are outlined in this article. Certainly there is some attraction to health, but even basic principles like this vary enormously across cultures. Bodily distortions such as small feet for adult women and stretched heads have been considered attractive. Studies to analyze human sexual preferences are extremely difficult and vulnerable to all kinds of bias, to date I have not found many studies on the subject that are particularly well done, but this is my limitation. It is important to bear in mind that humans are above all things a social species, and “cultural biases” are just as important to sexual preferences as are evolutionary biases.

    3. You mention innate xenophobia has a lot to do with our bias against the obese.

    Historically speaking, xenophobia is often created by the economic/political imperatives of a certain society. The best example of this was the “scientific racism” created by the ruling elite of Western Europe to justify the discrimination and oppression of people living all over the world. There is no reason why people of different groups cannot coexist, and in fact for much of human history they have managed to do so with limited conflict. Some kind of ingrained xenophobia does not hold up as a valid explanation in any area of discrimination, and especially here.

    If I may add my two cents to the obesity issue here, it is this:

    Cancer was once stigmatized as a disease contracted by those who were in some way sinful or deserving. The reason that view has changed (to some degree) has been the way the disease has been characterized (correctly) as a biological phenomenon, a disorder of cell proliferation and not some kind of mental/social/spiritual failing of an individual.

    Similarly, obesity is primarily a disease of fat metabolism. To boil it down, your fat cells get big, and then you do too. So if you can figure out what causes the fat cells to get really big, you get the problem. Bear in mind that this is a biological issue. You don’t fatten everywhere, only in certain places, so we can agree that there must some kind of biological (i.e. hormonal) regulation system to fattening. It stands to reason that some kind of dysfunction in that system would lead to abnormal levels of adiposity.

    To this end, there was a lot of great research done on this topic between the 1920s to 1970s. I suggest you look at it. A great place to start would be George Cahill’s work on fat metabolism and insulin, as well as that of Konrad Bloch and Feodor Lynen (who won a nobel prize for such work in 1964). Also good places to look would include the work of many German and Austrian physicians prior to world war 2. Google is a wonderful way to find these individuals. A science writer by the name of Gary Taubes has also written two good books about the subject, and is a good source to find many of these researchers and their work as well.

    If we continue to view obesity as a problem of individual failure, rather than understand the underlying basic biology behind it (and I don’t mean the effect of random pathways, mysterious chemicals, or vague environmental factors) it will encourage those who see the obese as exploitable scapegoats for their own motives to continue propagating a bias against them.