If we say that hypertension (elevated blood pressure) is injurious to blood vessels and by extension the cardiovascular system, I trust we can agree this is not insulting to blood vessels. It is, simply, a statement of fact- and one of outsized importance in modern epidemiology.
With that out of the way, perhaps we can also agree that words are to some extent like boots; wear them around for a while, and they are apt to take on a patina of dirt. You can scrub them, or replace them, but otherwise- the dirt is prone to become a distraction.
This has always been the case in the fraught epidemiologic space of “obesity,” whatever nomenclature has prevailed. We all know the many alternatives to “overweight” and “obese,” I trust, and a recitation is not required. All that have been used, in either clinical or public health settings or both, have taken on that tainted veneer; in some cases, simply because of routine use for some period of time, in other cases, because of overt abuse in the form of willful disparagement.
The challenge of talking about the public health problem of obesity has been compounded of late in the context of what is derided as “cancel culture.” The standards of political rectitude, or what I would prefer to call propriety, keep elevating. What was politically correct and acceptable 5 minutes ago is unlikely to remain so 15 minutes from now. Even those of us who genuinely mean no offense have a hard time keeping up; perhaps no one can keep their boots acceptably clean.
The attendant diffidence, if not overt reticence, is a public health threat of sorts in its own right. There is an expression from the world of business just as apt to the world of medicine and public health: we manage what we measure. The statement sometimes gets daylight in its negative guise: we don’t manage what we don’t measure.
Translated from the world of business to the domain of health, vital signs come immediately to mind. These are the indicators of the human condition deemed most…vital. They are, therefore, measured routinely as a prerequisite to their management. Their management is immanent to any version of the acceptable “standard” of clinical care.
But if we don’t manage what we don’t measure, how much less likely are we to manage what we seem reluctant even to mention? And so, we come back to the topic of obesity.
I can substantiate the causal pathway of concern here – discomfort even to mention leads to impediments to measure leads to failure to manage – from first-hand experience. In my many years as a clinical researcher, one among our priorities was to combat the epidemic (now pandemic) of childhood obesity with interventions in schools, where children could most readily be reached at scale. We routinely encountered resistance by administrators and school boards to the necessary measures that would establish BMIs for the children in their charge. The opposition was predicated on the “sensitivity” and potential stigma of the measures in question, notably- height and weight.
But there’s the rub: we have no hope of fixing what we are loathe to mention let alone measure. And fix it, we most certainly have not. Obesity in children has only ever worsened, and notably so during the COVID pandemic.
To be clear, I have great respect for the blight of stigma, its pernicious intrusion into all matters related to weight, and share with others a devotion to defense against the burden of it, for children especially but not exclusively. But we must be able to fight stigma without abandoning the fight against genuine maladies that siphon years from lives, and life from years. Overweight and obesity are, quite simply, on that list.
This is not open for debate, any more than the injurious effects of hypertension on blood vessels. Just as not every case of hypertension leads to stroke, not every case of overweight or obesity leads to demonstrable harm, either. But at the population level, each is very strongly associated with a higher rate of bad outcomes. That list of outcomes is long for obesity, with type 2 diabetes atop the list. As rates of obesity have risen among adults and children alike, rates of type 2 diabetes have followed in lock-step.
All of this is of acute as well as chronic concern. Rates of obesity have risen abruptly during the COVID pandemic. One could argue that the acute pandemic aggravated the chronic pandemic, and that the “favor” was then returned. Obesity has been strongly associated with severe COVID infection, hospitalization, and mortality. Most recently, a new study has shown that even “mild” COVID cases are more severe among those with overweight or obesity than among leaner counterparts.
While the acute pandemic, mediated by a virus, is only partially under our control, the chronic pandemic is entirely so. Yes, we could “fix” obesity if we were, as a culture, so inclined. Decades of tolerance for a toxic status quo suggest we are quite the opposite.
You, and I, and everyone else with access to news knows that our society actively propagates obesity and attendant chronic disease on the way to corporate profits; we have been told, more than once. Our food supply is booby-trapped to, at best, allow for obesity as collateral damage, and at worst, to aim at it.
We should not be blaming the victims of this, any more than we should “blame” everyone else with maladies amplified by the toxicities of our culture - everyone with diabetes, hypertension, heart disease, cancer, dementia, and more. But we should be confronting what drains so many years from lives and so much life from years with something that looks a lot less like complacency, and a lot more like outrage.
Propriety is important. But if our service to it stands between us and confrontation with a clear, omnipresent, and all-too-often lethal danger, something has gone preposterously wrong.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.