Tag Archives: obesity

When Science Fiction Seeks to Replace Science

2025 Weight Stigma Awareness Week (“WSAW”) is upon us. Much of what it stands for was clarified in 2023. That year, WSAW produced a white paper entitled, Impact Council White Paper (“ICWP”).

Click to access _%5BWSAW+2023%5D+Impact+Council+White+Paper.pdf

The ICWP states it, “… hosted an Impact Council roundtable with advocates, educators, clinicians, and leaders in healthcare, non-profit organizations, and media to discuss the greatest roadblocks to accessibility and inclusivity, as well as goals for the future.”

The ICWP has two major premises:

Premise 1 — “The medical community has done significant damage by promoting the idea that ‘obesity’ is a greater risk to individual and public health than weight stigma and anti-fatness are.”

Premise 2 — “Lived experience should be treated as credible data and prioritized (as much as or more than textbooks and quantitative research) for clinical recommendations and treatment plans.”

These are foundational, core premises at the heart of the weight stigma awareness movement. If these premises can be objectively proven to be accurate, then the corresponding recommendations and information arguably have more substance and merit and need to be thoroughly explored by a collaboration of organizations and professionals.

However, if the foundation, the core premises collapses, so does everything built upon them. The corresponding recommendations would be grounded in science fiction, not science, and if ever adopted, would inevitably result in doing greater harm to patients.

So, let’s explore more closely these two premises.

Premise One

“The medical community has done significant damage by promoting the idea that ‘obesity’ is a greater risk to individual and public health than weight stigma and anti-fatness are.”

There is no dispute that weight stigma is itself harmful to health. Stigma increases stress, social isolation, depression and anxiety, and can worsen cardiometabolic outcomes through behavioral (avoidance of care, disordered eating) and physiological (stress-axis) pathways. When clinicians stigmatize patients, it reduces trust and adherence and discourages preventive care (fewer screenings, delayed care).

Certainly, focus on BMI alone oversimplifies risk. BMI is an imperfect proxy for health; it doesn’t capture fitness, fat distribution, socioeconomic drivers, or comorbidities. Over-reliance on BMI can miss metabolically healthy people who need care and wrongly pathologize others.

Social determinants and structural drivers matter. Emphasizing individual “weight control” can obscure food access, economic inequality, built environment, racism, trauma, and other upstream determinants that shape both weight and health.

Even with this reality, the obvious flaws in the first premise are legion.

First, the medical and scientific communities without exception embrace the reality that there are measurable health risks associated with higher adiposity for many people. Epidemiologic studies link higher BMI (particularly when accompanied by central adiposity) to type 2 diabetes, osteoarthritis, some cancers, and cardiovascular disease. Discounting these risks wholesale would be irresponsible.

Further, there is a false dichotomy risk at issue. Framing this issue as “either stigma is the main harm or obesity is” sets up a false binary. In reality, both can be true: stigma causes harm and excess adiposity can increase risk for some outcomes. Policies must address both.

There is the aspect of public-health communication challenges. Minimizing messages about risk could reduce motivation for preventive behaviors in those who would benefit. Public health must balance non-stigmatizing language with clear information about risk and actionable steps.

There are other factors involved. There is heterogeneity of evidence and population differences. The magnitude of adiposity-related risk varies by age, sex, race/ethnicity, and metabolic profile. Broad absolute statements risk ignoring subgroups with high absolute risk.

One of the biggest flaws and drawbacks from the ICWP, is that the people behind the ICWP represent that the medical community has caused more damage by emphasizing that obesity is a greater risk to health than weight stigma and anti-fatness. They have phrased this issue using an absolute criterion while needlessly pointing fingers to assess blame. They have placed their own beliefs and interpretation of their own life experience at the forefront of this issue. They erred.

There are different study designs and evidence strength. The obesity→mortality evidence includes very large pooled prospective cohorts and individual-level meta-analyses (GBMC/Di Angelantonio et al.) with millions of participants and long follow-up that estimate dose–response relationships and cause-specific mortality. That level of evidence supports an accepted causal inference for some outcomes.

Contrarily, much of the stigma literature is smaller, newer, and more heterogeneous: cross-sectional studies, smaller cohorts, and observational work using self-reported stigma measures. Even the stronger longitudinal analyses are far smaller in scale than the pooled obesity cohorts. This difference in scale and design limits how directly you can compare effect magnitudes.

Second, there are measurement differences and misalignment of outcomes. Studies of obesity typically measure objective exposures (BMI, waist circumference, body composition) and hard outcomes (incident diabetes, MI, cancer, all-cause mortality).

Studies of stigma usually rely on self-reported experiences (e.g., “have you experienced weight discrimination?”) or internalization scales — valuable but inherently subjective and vulnerable to recall bias and reporting differences. Outcomes often include psychological measures, behavior change, intermediate biomarkers, or, in a few cases, mortality. These are not directly isomorphic to the obesity literature’s end points.

Third, there are confounding and directionality / causality problems. People who experience weight discrimination are, unsurprisingly, often higher weight; disentangling whether worse outcomes are caused by stigma per se or by the underlying higher adiposity (or by shared upstream causes) is difficult. The study conducted by Sutin et al. adjusted for BMI and some covariates and still saw an association, but residual confounding (socioeconomic factors, comorbid illness, lifetime exposures) and reverse causation (illness leading to both weight change and discrimination) remain plausible. Further, establishing causality (stigma → disease → mortality) requires randomized or natural-experiment evidence or sufficiently rich longitudinal mediation analyses; those are scarce.

Fourth, population attributable burden has not been estimated comparably. To claim, “stigma causes more harm than obesity,” we need comparable population-level metrics (e.g., population attributable fraction of mortality or years of life lost due to stigma vs due to elevated BMI). Those metrics exist for BMI (GBMC estimated mortality burden across BMI categories), but do not exist in a comparable, robust form for weight stigma.

The study by Sutin et al. reports an HR for mortality but translating that into population attributable mortality would require representative exposure prevalence estimates, reliable adjustment for confounders, and replication across populations.

What the best current evidence shows: Weight stigma is independently associated with worse mental health, adverse behaviors (disordered eating, activity avoidance), physiological stress markers, and — in at least two cohorts — higher mortality after adjustment for BMI and some covariates.

What the evidence does not show: There is no robust, widely accepted, population-level set of criteria demonstrating that weight stigma causes more total harm to population health (e.g., more deaths, more DALYs) than obesity itself. The obesity→mortality/evidence base is far larger, multi-cohort, and quantifies dose–response relationships; stigma literature is convincing in signaling independent harm but is currently smaller, less consistent, and lacks comparable population attributable estimates.

Clearly, the goal should be to move clinicians toward respectful, trauma-informed care; strengthen social-policy responses (food access, housing, anti-discrimination); and develop interventions that improve health without weight stigma.

So, should we be asking with this shared goal, why would the people behind the ICWP frame this issue as an absolute? Especially when they have no reputable, scientific, medical or socio-economic studies to support their position that an emphasis on obesity has caused more harm than anti-fat bias?

Without any reputable, third-party studies, they framed this issue as an absolute to fit their narrative. The tragic, unfortunate reality is the solution was right in front of them. All they had to do was rephrase this issue in a strong, evidence-based, factual manner … such as …

“Weight stigma and anti-fatness are inextricably intertwined with obesity and should be collectively classified as a public health issue. This would require the medical and scientific research communities to increase their research, study, understanding and treatment of these serious health issues on an equal basis.”

What is there to disagree with in that phraseology? This would have removed the finger pointing blame game perpetrated by the ICWP and would have provided a collaborative way forward together. But that was not to be. And the reasons for that lack of vision are set forth in our analysis of Premise No. 2.

Premise No. 2

“Lived experience should be treated as credible data and prioritized (as much as or more than textbooks and quantitative research) for clinical recommendations and treatment plans.”

The second central premise—that lived experience should be prioritized above textbooks and quantitative data—turns medical practice into witch doctory and personal storytelling. This is not a serious framework for healthcare; it is activism dressed up as evidence.

The problems with this premise are legion.

There are obvious methodological problems. Anecdotes do not constitute medical evidence. Individual stories can be powerful but lack controls, generalizability, and statistical rigor. Treatment guidelines based on lived experience risk being skewed by outliers or vocal subgroups.

There are also bias and recall issues. Patients may unintentionally misreport causes, timelines, or treatment responses due to memory bias, emotional interpretation, or secondary gain.

We are also required to consider over-representation of advocates and activists. Those most active in advocacy or online discourse are often not representative of the broader patient population, creating sampling bias.

Then there is the risk of undermining evidence-based care. There is “treatment drift.” Prioritizing anecdotes could encourage clinicians to substitute “what worked for one person” for protocols validated across thousands in trials.

The medical community must also consider neglect of biological mechanisms. Obesity and eating disorders involve complex neurobiological, metabolic, and genetic components. Patient narratives may not reflect these dimensions.

There is also false equivalence. Equating lived experience with systematic research elevates subjective impressions over reproducible science, undermining evidence hierarchies critical for patient safety.

For obesity, some narratives reject all weight management as “harmful,” ignoring evidence that structured interventions improve metabolic outcomes. This can fuel distrust of effective therapies.

The medical and scientific research communities would inevitably experience ethical and legal challenges and concerns.

There is standard of care liability.  If guidelines deviate from established evidence to favor lived experience, clinicians risk malpractice exposure when outcomes are poor.

There are also equity gaps. Vocal groups whose experiences get prioritized, may dominate marginalized, silent or less empowered populations.

Potential conflicts of interest exist. Patient advocates with financial or ideological agendas could influence treatment norms, displacing objective science.

The systemic consequences of this misguided belief are obvious and notorious. This belief would lead to an erosion of research investment at a time when research grants have been eradicated. If lived experience is placed on equal or higher footing, incentives to conduct rigorous trials would diminish, weakening long-term scientific progress.

It would also result in fragmentation of care standards. Different doctors, clinics and treatment centers might prioritize different anecdotal narratives, leading to inconsistent, non-comparable practices.

Most alarmingly, obesity and eating disorders already carry high morbidity and mortality; steering care away from empirically validated interventions risks worsening public health outcomes.

Again, we should be asking why would the people behind the ICWP frame this issue as an absolute? Especially when they have no scientific, medical or socio-economic studies to support their position?

The ICWP had the ability to reconcile both premises into a practical clinical and policy approach. They chose not to. Perhaps one of the co-founders of Weight Stigma Awareness Week gave us the reason for this ill-fated, Quixotic position when she said, “It bothered me that all the air was taken by a white perspective … This is no space for white, straight and thin folks to jump in … Those of us who have done the work around our internalized biases no longer trust the medical establishment to actually help us.” … Public health in this country is getting it so wrong and there is a better way, but we need to be willing to actually listen to those being harmed.”

These people are not embracing science. They are embracing science fiction.

Perhaps the answer to all legitimate questions asked above is simply … to maintain their voice, to assuage their feelings of pain, self-loathing and anger, the maladjusted, militant fat activists must embrace their own reality because society will not.

The ICWP fails

The ICWP fails at the starting line. Its first major claim—that medicine has caused more damage by warning about obesity than by neglecting weight stigma—is not just wrong, it is reckless. It is divisive. It dismisses decades of clinical evidence linking obesity to disease and early death, replacing science with ideology.

Its second central premise—that lived experience should be prioritized above textbooks and quantitative data—turns medical practice into guesswork and personal storytelling. This is not a serious framework for healthcare; it is radical advocacy dressed up as evidence.

Beyond the flawed premises, the rhetoric in the ICWP itself gives the game away. The authors rely on moralizing language and sweeping accusations, framing the medical community as a monolithic villain rather than engaging with the nuance of scientific debate. Raw emotion is substituted for data, using anecdotes and identity politics to demand deference in place of proof. This kind of rhetorical sleight of hand may stir outrage, but it does not withstand scrutiny.

When the core assumptions collapse, so does everything built upon them. The ICWP is not grounded in science but in science fiction. Far from being an authoritative white paper, it is merely a manifesto masquerading as scholarship, and it deserves to be treated as such.

Tragically … it did not have to be like that. But, when so-called leaders place the manifestations of their own mania before reputable, medical and mental health based criteria, their message is lost. The Power of the Message is lost.

And all that is left is chaos, shattered dreams, and the final, weak beats of a Tell-Tale Heart.

Obesity*, Mental Disorders … and the DSM-VI?

In my freshman year of college (before cell phones, the internet and electricity were invented), to satisfy required science credits, I took Philosophy 101. Our introduction to deductive reasoning included the following :

P1). All mammals have lungs.

P2). All dogs are mammals.

C). Therefore, all dogs have lungs.

The conclusion necessarily followed from Premise 1 and 2. IF P1 and P2 are true, and the subject matter is common, then it follows that C must be true. This is a prime example of deductive reasoning. But, is that always the case? For example:

P1). All dogs are mammals.

P2). All cats are mammals.

C). Therefore, all dogs are cats.

In this case, unquestionably Premise 1 and 2 are both correct. Both involve a common subject matter, that is, mammals. But, the conclusion does NOT necessarily follow even though Premise 1 and 2 are correct and the subject matter of the premises is similar. This illustrates the only instance in which deductive argument is invalid, that is, when a faulty conclusion is drawn from two premises, which when viewed in isolation, are accurate.

Which brings us to issues involving Obesity, eating disorders and mental disorders.  *To begin with, I am aware that the terms “Obese” or “Obesity,” have become  almost terms of derision amongst a growing number of people. They postulate that these terms reflect outdated and inaccurate measures by which a diagnosis is based. And yet, to facilitate easier understanding of this article, I will use this term as it is defined by a number of authoritative entities. For example, the National Institutes of Health, define Obesity as someone having a Body Mass Index of 30 and over.   So, let us commence.

The Deductive Argument Analysis

P1). Obesity has a biological, genetic, environmental and/or psychological component to it.

P2) All mental disorders have a biological, genetic, environmental and/or psychological component to them.

C). Therefore, Obesity is a mental disorder.

In this example, Premise 1 and 2 are correct. Both involve a common subject, that is, a biological, genetic, environmental or psychological component. But, the conclusion does NOT necessarily follow even though Premise 1 and 2 are correct and the subject matter of the premises is similar. However, if this deductive argument is accurate, then an evolution in the manner in which Obesity is defined, researched and treated is necessary.

This brings us to our essential inquiry: Does sufficient evidence now exist supporting the premise that Obesity should now be classified as a mental disorder and included as such in the next DSM-VI?

What is a Mental Disorder?

In the DSM-V, published in 2013, “mental disorder” was defined as:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

This definition seems to be a bit wordy. As previously note, Albert Einstein is on record as saying, “If you can’t explain it to a six year old, you don’t really understand it.” This definition is broad, yet vague, expansive yet finite. It expands on the definition of “mental disorder” as defined in previous DSMs. And yet, in an article published in the July 2013 edition of Psychology Today  authored by Eric Maisel, PhD, Dr. Maisel stated: “The very idea that you can radically change the definition of something without anything in the real world changing and with no new increases in knowledge or understanding is remarkable, remarkable until you realize that the thing being defined does not exist. It is completely easy—effortless, really—to change the definition of something that does not exist to suit your current purposes. In fact, there is hardly any better proof of the non-existence of a non-existing thing than that you can define it one way today, another way tomorrow, and a third way on Sunday.” The foundation for Dr. Maisel’s opinion is based in his disbelief in the existence of God.

This definition has been widely criticized for a number of reasons. The newer definition greatly expanded previous definitions although critics could find no scientific breakthroughs supporting this expansion. It has been called overreaching. Other justified criticism exists as well.

So, as unsatisfying as this definition may be, at this point, let us work with what we have and toddle on to the next inquiry.

What is Obesity?

In 2010, the National Institutes of Health defined Overweight as persons with a BMI of 25.0 – 29.9; Obesity as persons with a BMI over 30.0, and; Severe Obesity as persons with a BMI exceeding 35.0. [And yes again, I am aware of the arguments against using BMI as an accurate measure of health and that persons in larger bodies can enjoy “good health.” But, that is the subject for another article].

In general, Obesity refers to an excess of body fat. In the broadest sense, Obesity results from an imbalance between energy intake and energy expenditures.

So, whether its definition is limited to this definition of BMI as set forth by the NIH, or involves a more expansive and all encompassing definition, the fundamental issues remains; Is Obesity a mental disorder and should it be included in the next DSM-VI?

Historical Perspective

Previously, the Eating Disorder Work Group of the DSM 5th Edition Task Force was given the responsibility for determining whether Obesity was a mental disorder that should be included in the DSM-V.

Ultimately, the Work Group did not find compelling, sufficient evidence to support establishing Obesity as a mental disorder and concluded that Obesity would not be included in the DSM-V. The Work Group reasoned that Obesity is a heterogeneous condition with a complex and incompletely understood etiology. Since that time, more research and study have been conducted on Obesity and its etiology.

In 2013, just after the DSM-V was published, the American Medical Association’s House of Delegates voted overwhelmingly to “recognize Obesity as a “disease state” with multiple pathophysiology aspects requiring a range of interventions to advance obesity treatment and prevention.”

We must still go further.

Is Obesity a Mental Disorder?

To conduct this analysis, we turn to the works of Dr. Jerome C. Wakefield. Dr. Wakefield has been a university professor at NYU since 2003. His areas of expertise include conceptual foundations of clinical theory and the philosophy of psychopathology.

Professor Wakefield’s definition of mental disorder focuses on “harmful mental dysfunction” and was proposed for inclusion in the DSM-V. Although ultimately, his definition was not included, Professor Wakefield believes his alternative definition improves the validity and diagnosis of mental disorder constructs.

To this end, Professor Wakefield wrote:

“A condition is a mental disorder if and only if:

(a). the condition causes some harm or deprivation of benefits to the person as judged by the standards of the person’s culture, and;

(b). the condition results from the inability of some mental mechanism to perform its natural function, wherein a natural function is an effect that is part of the evolutionary explanation of the existence and structure of the mental mechanism.”

In short, the Wakefield approach focuses on the concept of harmful mental dysfunction. And dysfunction exists when a person’s internal mechanisms are not able to function in the range of environments for which they were designed.

Is Obesity Harmful?

Again, we are using (without commenting on the accuracy, inaccuracies or shortfalls) the NIH’s definition of Obesity. If the NIH’s definition of Obesity is adopted, most medical professionals assert that Obesity is harmful for most individuals. Obesity has been recognized as a base condition that could lead to or worsen cardiovascular disease, diabetes, hypertension, kidney disease, obstructive sleep apnea, and osteoarthritis.

Obesity also is associated with significant psychosocial impairment. Persons with a higher BMI have been subject to weight-based stigma and discrimination, generally report poorer quality of life and are subject to stressors and derision that low BMI persons do not experience. That there is weight discrimination is not debatable.

At a societal level, there are profound economic consequences associated with persons with a higher BMI in the form of fewer economic opportunities, increased medical costs and a medical community which languishes in past beliefs and who have not studied not embraced the many societal obstacles placed before persons with a higher BMI and the manner in which those obstacles psychologically impact persons with a higher BMI.

Accordingly, few could argue that Obesity clearly satisfy the first element in the Wakefield Mental Disorder Concept.

What evidence exists establishing that Obesity is Caused by Mental Dysfunction?

This issue stymied the Eating Disorder Work Group and formed the basis for their denial of inclusion. Subsequent to that decision, evolving times have given greater clarity,

As previously stated, the AMA classified Obesity as a disease.

In the last 10 years, genetic research has made tremendous leaps forward. Studies indicate that gut microbiome influence metabolism and energy extraction from food. One research study involving family history and twins documented that 40% – 70% of the variance in Obesity can be accounted for by genetic factors.

Dr. Joseph M. Pierre, a Health Sciences Clinical Professor at the School of Medicine at UCLA stated: “Highlighting the behavioral core of obesity is not to be equated with saying that freely-willed choices about eating are the root-cause of obesity. On the contrary, it would be more correct to say that obesity, just like any other psychiatric disorder, represents a dysfunction involving genetics, anatomy, physiology, and environmental factors that results in an inability of the brain to properly regulate behavior. In the case of obesity, the brain must ultimately decide whether to eat based on hunger, satiety, and other factors, but that decision is an action influenced by things going on in other places in the body.”

In the same article, Dr. Pierre categorized Obesity as a possible addiction issue. He stated: “Still, we now have compelling animal models for addiction, with reasonably clear outlines of the neural pathways in the brain that govern behaviors associated with reward and loss of control. This has helped to build a strong case for modeling addiction as a psychiatric disorder, a viewpoint that is now widely embraced by the medical community, if still debated in other circles including the legal system. Just so, best practice addiction therapy now involves the combination of psychotherapy as well as pharmacotherapy, with several medications now approved by the Food and Drug Administration (FDA) for the treatment of alcohol dependence. 

He further opined: “Many researchers have applied an addiction model to at least some forms of obesity, noting similarities in terms of the immediate psychological rewards one derives from eating, a loss of behavioral control, and overlapping neural systems underlying “appetitive and consummatory behaviors.” Again then, adopting a psychiatric model for obesity hardly seems a stretch.”

The progress made in the genetic and biological understanding of Obesity warrants a serious, long look as to whether thew scientific and medical communities are now able to satisfy the definitions of “mental disorder” or mental dysfunction. And if Obesity falls under the umbrella of mental disorders, then the rules of the game will dramatically change.

RAMIFICATIONS OF THE REDEFINING OF OBESITY

Assuming the latest research studies support the finding that Obesity is in fact, a mental disorder, the benefits and positive aspects of this classification are many and varied. First, it could be argued that Obesity would garner renewed attention and study from psychiatrists in a more objective manner. These medical professionals seek to understand behavior from both psychological and medical perspectives and routinely combine behavioral interventions with somatic therapies.

Recognizing Obesity as a mental disorder could result in greater public understanding of Obesity. This could lead to more federal and state funding for public health programs and greater financial reimbursement by insurance companies for treatment. On the issue of stigma, a disease model could temper stereotypes about laziness and lack of self-control resulting in greater acceptance of the complex etiology of obesity. 

From a legal perspective, in general, courts have held that Obesity is not a disability under the Americans with Disabilities Act. (“ADA”) Under the ADA, to qualify as a disability, a physical or mental impairment must substantially limit a major life activity. If Obesity was determined to be a mental disorder, courts would be forced to reassess future cases in which the claimant claimed protection under the ADA. 

Weight discrimination would no longer just be a rallying cry by those who have been oppressed. Now, they would have legal ammunition to strike back against those entities which have historically practiced weight discrimination.

CONCLUSION

A greater understanding of all aspects of “Obesity” is long past due. And assuming that the studies being conducted and continued biological and genetic research support such conclusion, we would have to rethink the conclusion from our prior deductive argument:

P1). All mental disorders have a biological, genetic, environmental and/or psychological component to them.

P2). Obesity has a biological, genetic, environmental and/or psychological component to them.

C). Therefore, Obesity is a mental disorder.

Based upon a greater medical, scientific and psychological understanding and the breakthroughs in the last ten years, this conclusion could necessarily follow. This in turn, would necessarily supply the groups like HAES with legal ammunition to better spread their message and bring strength and clarity to their vision.