Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2006;35:55–60
Ó The Author 2005; all rights reserved. Advance Access publication 8 December 2005 doi:10.1093/ije/dyi254
The epidemiology of overweight and obesity:
public health crisis or moral panic?
* Abigail Saguy,
and Glenn Gaesser
National and international health organizations have focused
increasingly on a perceived obesity epidemic said to pose drastic
threats to public health. Indeed, some medical experts have gone
so far as to predict that growing body mass will halt and perhaps
even reverse the millennia-long trend of rising human life
In response to such concerns public health agencies
across the world have sprung into action, searching for policies
or incentives to mitigate the alleged ‘disease’ of obesity.
Yet even as the volume of alarm grows louder, a growing
number of researchers, drawn from a broad array of academic
disciplines, are calling these claims into question. The authors of
this article come from this latter group. In our view the available
scientific data neither support alarmist claims about obesity nor
justify diverting scarce resources away from far more pressing
public health issues. This article evaluates four central claims
made by those who are calling for intensifying the war on fat:
that obesity is an epidemic; that overweight and obesity are major
contributors to mortality; that higher than average adiposity
is pathological and a primary direct cause of disease; and that
significant long-term weight loss is both medically beneficial
and a practical goal. Given the limited scientific evidence for any
of these claims, we suggest that the current rhetoric about an
obesity-driven health crisis is being driven more by cultural and
political factors than by any threat increasing body weight may
pose to public health.
Claim #1: ‘Almost all countries (high-income and low-
income alike) are experiencing an obesity epidemic ...’
WHO, 2003 (p. 61).
The claim that we are seeing an ‘epidemic’ of overweight
and obesity implies an exponential pattern of growth typical of
epidemics. The available data do not support this claim. Instead,
what we have seen, in the US, is a relatively modest rightward
skewing of average weight on the distribution curve, with people
of lower weights gaining little or no weight, and the majority
of people weighing ~3–5 kg more than they did a generation
The average American’s weight gain can be explained by
10 extra calories a day, or the equivalent of a Big Mac once
every 2 months. Exercise equivalents would be a few minutes of
walking every day. This is hardly the orgy of fast food binging and
inactivity widely thought to be to blame for the supposed fat
While there has been significant weight gain among the
the vast majority of people in the ‘over-
weight’ and ‘obese’ categories are now at weight levels that are
only slightly higher than those they or their predecessors were
maintaining a generation ago. In other words we are seeing
subtle shifts, rather than an alarming epidemic. Biologist Jeffery
Friedman offers this analogy: ‘Imagine that the average IQ was
100 and that five percent of the population had an IQ of 140
and were considered to be geniuses. Now let’s say that education
improves and the average IQ increases to 107 and 10% of the
population has an IQ of .140. You could present the data in
two ways. You could say that average IQ is up seven points or
you could say that because of improved education the number
of geniuses has doubled. The whole obesity debate is equivalent
to drawing conclusions about national education programmes
by saying that the number of geniuses has doubled.’
In the US, to take a much-cited example, the so-called ‘obesity
epidemic’ is almost wholly a product of tens of millions of
people with BMIs formerly in the 23–25 range gaining a modest
amount of weight and thus now being classified as ‘overweight’,
and, similarly, tens of millions of people with BMIs formerly
in the high 20s now having BMIs just .30. This movement of
population cohorts from just below to just above the formal
definitions of overweight and obesity is what public health
officials are referring to when they point out that rates of obesity
have exploded over the course of the last generation. (Further-
more, there is some evidence that adult and childhood BMI may
have ceased to increase, as shown by comparison of NHANES
data from 1999 to 2000 and from 2001 to 2002).
In any case the real question is whether these developments
represent some sort of genuine health crisis. This is true only if
crossing the threshold of BMI 25 or 30 is analogous to contracting
a life-threatening disease. But this analogy holds only to the
extent that overweight and obesity actually cause increased
Claim #2: ‘Mortality rates increase with increasing degrees
of overweight, as measured by BMI.’—WHO, 2003 (p. 61)
This claim, central to arguments that higher than average
body mass amount to a major public health problem, is at best
School of Law, University of Colorado, CO, USA.
Department of Sociology, University of California, Los Angeles, CA, USA.
Department of Nutrition, Case Western Reserve University School of
Medicine, OH, USA.
Department of Political Science, University of Chicago, Chicago, IL, USA.
Curry School of Education, University of Virginia, VA, USA.
* Corresponding author. E-mail: firstname.lastname@example.org
weakly supported by the epidemiological literature. Except at
true statistical extremes, high body mass is a very weak predictor
of mortality, and may even be protective in older populations. In
particular, the claim that ‘overweight’ (BMI 25–29.9) increases
mortality risk in any meaningful way is impossible to reconcile
with numerous large-scale studies that have found no increase
in relative risk among the so-called ‘overweight’, or have found
a lower relative risk for premature mortality among this cohort
than among persons of so-called ‘normal’ or ‘ideal’ [sic] weight.
Among the obese, little or no increase in relative risk for
premature mortality is observed until one reaches BMIs in the
upper 30s or higher. In other words, the vast majority of people
labelled ‘overweight’ and ‘obese’ according to current definitions
do not in fact face any meaningful increased risk for early death.
Indeed the most recent comprehensive analysis of this question
within the context of the US population found more premature
deaths associated with a BMI of ,25 than with a BMI above it.
This was largely owing to the finding that lowest death rates fell
within the BMI range of 25–29.9—some 86 000 fewer ‘excess’
deaths than was observed in the referent group, the so-called
‘normal weight’ BMI range of 18.5–24.9. Additional analyses
that controlled for potential confounders such as length of
follow-up, weight stability, weight loss caused by illness, or
smoking status did not change the results. For this nationally
representative cohort of US adults—National Health and
Nutrition Examination Surveys I, II, and III—the ‘ideal’ weight
for longevity was ‘overweight’.
These most recent findings from the NHANES data should
come as no surprise. Data from NHANES I published in 1998
revealed essentially the same thing—a U-shaped relationship
between BMI and mortality. Significantly increased mortality
was only associated with either extreme of BMI. As noted by
the authors, ‘the resulting empirical findings from each of
the four race/sex groups, which are representative of the US
population, demonstrate a wide range of BMIs consistent with
minimum mortality and do not suggest that the optimal BMI is
at the lower end of the distribution for any subgroup’.
These findings from representative US cohorts are consistent
with global observations. In a quantitative analysis of a number
of previously published studies, involving .600 000 men and
women, Troiano et al.
observed a similar U-shaped relationship
between BMI and mortality, with the lowest mortality rates
between BMIs of 23 and 29. Most of the range considered
‘overweight’ was not associated with higher risk. On the other
hand, low BMI was. For example, mortality rates for men with
BMIs between 19 and 21 were the same as those for men with
BMIs between 29 and 31. Troiano et al. emphasized that, ‘this
quantitative analysis of existing studies revealed increased
mortality at moderately low BMI for white men comparable
with that observed at extreme overweight, which does not
appear to be due to smoking or existing disease. Attention to
the health risks of underweight is needed, and body weight
recommendations for optimum longevity need to be considered
in light of these risks.’
Rarely do the risks of thinness get any media attention. In the
recent Flegal study,
for example, underweight (BMI , 18.5)
was associated with an estimated 33 746 excess deaths, despite
the very small percentage (2.7%) of the subject pool that was in
this category. In most of the NHANES cohorts, the relative risks
associated with underweight were greater than those associated
with even high levels (BMI . 35) of obesity. Furthermore, when
Flegal and her colleagues used a BMI range of 23–24.9 as the
referent category, underweight (BMI , 23) was associated with
81 705 excess deaths. In other words, including men and women
in the lower end of the ‘normal weight’ range increased the
number of deaths associated with thinness by nearly 48 000. Of
course, if the referent BMI group had been in the BMI range of
25–29.9, the excess deaths associated with being underweight or
‘normal weight’ would have exceeded 100 000, with the majority
of these coming from the BMI range currently defined as
But the greatest problem with the statistical linkages between
body mass and mortality is that other confounding factors are
not considered, leaving little basis for drawing causal inferences.
Most epidemiological studies estimating the relationship
between body weight and mortality do not control for fitness,
exercise, diet quality, weight cycling, diet drug use, economic
status, or family history. Furthermore, in studies that control
for some of these factors, the data are usually self-reported and
thus of extremely questionable reliability. (See, for example, the
five-point exercise scale used in the Nurses’ Health Study.) By
contrast, when one or more confounders are controlled for in a
rigorous fashion, the already weak association between higher
body mass and greater mortality tends to be greatly attenuated
or disappear altogether. For example, all of the excess mortality
associated with obesity in the Framingham study can be accoun-
ted for by the impact of weight cycling.
residents with stable body weights were not at increased risk. The
same result has been obtained in NHANES.
Fitness is closely intertwined with obesity, and has powerful
influences on health and mortality. Data from the Aerobics
Center Longitudinal Study show that low cardiovascular fitness
accounted for all of the excess all-cause mortality among obese
Similar data by these researchers have been reported
In short, it seems probable that body weight,
like height or baldness, is for the most part a proxy for many
unmeasured variables. From a public health perspective, the
most significant aspect of such a conclusion is that most of these
unmeasured variables, especially the lifestyle factors, are more
readily modifiable than body mass.
Many common weight loss treatments generate particularly
problematic confounders. For example, over-the-counter diet
pills used by millions, including phenylpropanoloamine and
herbal ephedra, have been linked to heart attack and strokes
and recently banned.
The adjusted odds ratio for stroke in
women taking phenylpropanolamine for weight loss was 16.6,
many times higher than the relative risk for stroke associated
with a BMI . 30, which in one typical study was 1.29 (not
And the higher a person’s BMI, the more likely
they are to use these and other hazardous weight loss methods,
including surgery. One study found that 22% of weight loss
clinic clients surveyed used phenylpropanoloamine for weight
If only one in 13 obese persons were exposed to over-
the-counter diet pills containing phenylpropanolamine, then all
of the excess risk of obesity could be accounted for by increased
diet pills use. No epidemiological study to date has assessed
mortality risks after taking the known hazards of stimulant diet
pills into account.
In short, the causal links between high and low body mass
and increased mortality remains highly speculative. We actually
56 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
know little about why the very thin and the very heavy are more
likely to die than those in the ‘normal,’ ‘overweight’, and ‘Type I
obese’ (BMI 5 30–34.9) categories, and it is likely that there
are multiple causal pathways across the weight spectrum. For
instance, intervening with dietary supplementation to cause
weight gain in underweight elderly persons has been shown to
reduce mortality and prolong survival.
valent data showing that weight loss in obese persons reduces
mortality are lacking.
Claim #3: ‘The data linking overweight and obesity to
adverse health outcomes are well established and
When the weakness of the epidemiological link between
BMI and health risk is pointed out, it is sometimes asserted that
BMI is an inexact measure of adiposity and that high levels of
body fat, rather than high body mass per se, represent the real
health risk. Yet when epidemiological studies have compared
BMI with percentage of body fat as a marker for disease risk,
BMI is consistently superior to percentage of body fat.
suggests that body build rather than fatness may be the source of
risks associated with high BMI. Despite much speculation, very
little evidence has been produced regarding the question of
exactly how adiposity is supposed to cause disease. With the
exception of osteoarthritis, where increased body mass contrib-
utes to wear on joints,
and a few cancers where oestrogen
originating in adipose tissue may contribute,
between body fat and disease remain hypothetical. It is quite
possible, and even likely, that higher than average body fat is
merely an expression of underlying metabolic processes that
themselves may be the sources of the pathologies in question.
For example, much evidence suggests that insulin resistance
is a product of an underlying metabolic syndrome that also
predisposes persons to higher adiposity because compensatory
insulin secretion promotes fat storage. Modern molecular
genetics confirms the thrifty gene hypothesis that mutations
favouring fat storage and survival of famine also confer risk of
Thus, obesity may be an early symptom of diabetes
rather than its underlying cause.
The claim that adiposity is itself pathological is also belied by
the results of interventions that remove body fat from their
subjects. For instance, a recent study involved removing an
average of 10 kg of body fat (by liposuction) from 15 female
subjects. The study found no improvements in any health
markers over the next 10–12 weeks, during which time the
women were contacted weekly by researchers, to reinforce the
importance of not changing their diet or physical activity.
This contrasts with the significant improvements in health
associated with much smaller amounts of fat loss produced by
programmes designed to decrease weight through lifestyle
modification. Such contrasting results suggest strongly that the
diet and exercise modifications undertaken by the subjects in
these programmes, rather than any subsequent loss of body
fat, are the causes of the observed health improvements.
Indeed, disentangling the presumed cause-effect link between
body fat and ‘weight-related’ health problems is fairly straight-
forward. Exercise and nutrition can effectively reduce blood
pressure—an effect that is independent of changes in body
In the DASH trial the reductions in blood pressure
among participants with hypertension were comparable with
those achieved with pharmacotherapy. Blood lipids can also be
improved with changes in exercise and diet, largely independent
of changes in body weight or body fat.
Improvements in insulin sensitivity and blood lipids as a
result of aerobic exercise training have been documented even
in persons who actually gained body fat during the interven-
This outcome is entirely inconsistent with prevailing
beliefs about body fat and health. It is also important to note that
these are not new findings. Despite having been available to
the scientific community for 35 years, these ‘non-conforming’
findings remain largely ignored.
So too have the data showing that some body fat depots,
particularly subcutaneous fat on the hips and thighs, may
actually provide significant health benefits.
Thigh and hip
fat in particular have been reported to be associated with lower
plasma triglycerides and higher HDL-cholesterol levels.
researchers in one report noted that, ‘the total amount of fat in
legs and hips was negatively correlated with risk of cardiovas-
In the Nurses’ Health Study, women who were
overweight to extremely obese (BMIs between 25.2 and 48.8)
with large hips and small waists had a coronary heart disease
risk that was only one-half that of women of about average, or
slightly less than average, weight (BMIs between 22.2 and 25.2)
who had small hips relative to their waists.
In other words,
the build or shape of the body seems to matter more than its
That some body fat depots are actually protective may explain
the published documentation of ‘metabolically normal’ obese
persons, i.e. ‘fat’ men and women with entirely normal
Such individuals are most likely at their
own natural healthy weight, and do not need ‘treatment’.
illustrates a more general point: discussions about obesity and
overweight as a health risk tend to treat weight as a health
behaviour, akin to smoking.
Thus overweight and obesity
are commonly referred to as ‘preventable causes of illness’. Yet
the relationship between behaviour and weight is complex,
and intertwined with immutable factors such as genetics, and
body build and shape. The average individual’s control over his
or her weight is limited at best. This brings us to Claim #4.
Claim #4: Significant long-term weight loss is a practical
goal, and will improve health.
At present, this claim is almost completely unsupported by
the epidemiological literature. It is a remarkable fact that the
central premise of the current war on fat—that turning obese
and overweight people into so-called ‘normal weight’ individuals
will improve their health—remains an untested hypothesis.
One main reason the hypothesis remains untested is because
there is no method available to produce the result that would
have to be produced—significant long-term weight loss, in
statistically significant cohorts—in order to test the claim. It is
particularly striking that studies that have found health benefits
associated with various levels of weight loss generally record no
dose response: in other words, people who lose a small amount
of weight, or even gain weight, get as much health benefit from
the intervention as those who lose larger amounts.
Data from the National Health Interview Survey (follow-up
from 1989 through 1997) illustrate the point. Among overweight
THE EPIDEMIOLOGY OF OVERWEIGHT AND OBESITY 57
and obese men and women, with and without type 2 diabetes,
those who reported trying to lose weight (but without success)
experienced a reduction in mortality rate that was the same as,
or greater than, those who reported that they were successful
at weight loss. In other words weight loss itself did not appear
to be beneficial.
Indeed, in this same study, weight loss was
associated with a mortality hazard ratio of 3.36 and weight
cycling with a hazard ratio of 1.83.
By contrast, obese people
with stable body weight had no increase in mortality.
On the whole, body weight seems like a poor target for public
health remediation, particularly in the absence of any safe or
effective tools for weight loss. Furthermore, many of the tools
that are currently employed towards that end (diet drugs, weight
loss surgery, eating disordered behaviour, fad diets, and the
chronic weight cycling they induce) have serious side effects,
up to and including death. Thus public health interventions
designed to lessen rates of obesity and overweight are striving
to achieve a presently unachievable goal of unknown medical
efficacy. In contrast, as noted above, many studies have found
striking health benefits associated with lifestyle changes that
produce little or no long-term weight loss. Furthermore, dozens
of double blind randomized controlled clinical trials have
shown that obese patients are protected from death and heart
disease by lipid lowering and antihypertensive medications,
without losing any weight whatsoever. One class of drugs, the
thiazolidinediones, improves multiple risk factors in obese
diabetics while causing significant increases in body fat.
Under such circumstances, for public health agencies to focus
on trying to make people thinner, at the potential expense of
initiatives that will improve lifestyle but are unlikely to produce
significant long term weight loss, seems grossly inefficient.
Social and political contributors to
the obesity panic
Despite the lack of scientific data supporting the central claims
of the war on fat, overweight has been a growing object of
governmental and popular concern. In recent years, claims that
obesity is a serious public health problem on both a national and
international level have become epidemic. For instance, between
1980 and 2004, media attention to obesity increased exponen-
tially, from 62 articles published in the Lexis-Nexis US News
Sources with ‘obesity’ in the headings, lead paragraphs, or key
terms in 1980, to over 6500 in 2004.
If such heightened
concern does not reflect scientific reality, what is driving it?
Part of the answer may lie with overlapping (and often
conflicting) set of economic interests among various public
health constituencies. For example, many of the leading obesity
researchers who have created the official standards for what
constitutes ‘overweight’ and ‘obese’ have also received sizable
funding from the pharmaceutical and weight-loss industries.
These obesity researchers also manage weight loss clinics and
have an economic interest in defining unhealthy weight as
broadly as possible, by overstating the hazards of obesity, and
thus providing justifications for regulatory approvals, as well as
for government and insurance industry subsidization of their
products. In particular, organizations like the International
Obesity Task Force (which has authored many of the WHO
reports on obesity) and the American Obesity Association (which
has actively campaigned to have obesity officially designated
as a ‘disease’) have been largely funded by pharmaceutical
and weight-loss companies. Notably, although expert panels on
obesity are largely devoted to evaluating epidemiological evi-
dence and claims, qualified epidemiologists are almost never
included as members. In addition, government health agencies,
like the Centers for Disease Control and Prevention in the United
States, have promoted the urgency of the ‘obesity epidemic’
while lobbying for greater programme funding and policy
Targeting obesity has support across the political spectrum.
In the US, discussions of the supposed obesity epidemic usually
take place within the context of a larger discussion, which
assumes that the increasing weight of the population is a sign of
increasing moral laxity and that overweight and obesity are
playing a significant role in driving up health care costs. This
linkage is attractive for those who are ideologically committed to
a focus on ‘individual responsibility’, rather than on structural
factors that continue to drive health care costs ever upward, and
leave one out of every seven Americans without health
insurance of any kind.
Anxieties about increasing weight
resonate with those on the left of the political spectrum as well,
who tend to interpret the ‘obesity epidemic’ as both a by-product
and a symbol of rampant consumer overconsumption and greedy
The exponential increase in mass media attention to obesity
in the US and abroad seems to have many of the elements of
what social scientists call a ‘moral panic’. Moral panics are typical
during times of rapid social change and involve an exaggeration
or fabrication of risks, the use of disaster analogies, and the
projection of societal anxieties onto a stigmatized group.
Despite the very weak evidence that obesity represents a
health crisis, scientific studies and news articles alike continue
to treat the population’s weight gain as an impending disaster.
A content analysis of 221 press articles discussing scientific
studies of obesity found that over half employed alarming
metaphors such as ‘time bomb’.
This same study also found
that .60% of the news blamed obesity on individual choices,
while only ~30% discussed any structural factors that might
influence weight gain. Articles that reported on blacks or Latinos
were over eight times more likely than articles that did not
blame obesity on bad food choices, and over 13 times more likely
to blame it on sedentary lifestyles, while articles reporting on
the poor were four times as likely as other articles to blame
obesity on sedentary lifestyles. Such findings lend support to the
theory that talk of an ‘obesity epidemic’ is serving to reinforce
moral boundaries against minorities and the poor.
Public opinion studies also show that negative attitudes
towards the obese are highly correlated with negative attitudes
towards minorities and the poor, such as the belief that all
these groups are lazy and lack self-control and will power. This
suggests that anxieties about racial integration and immigration
may be an underlying cause of some of the concern over
Consider the apocalyptic conclusion of a cover story
in a prominent American magazine:
What do the fat, darker, exploited poor, with their unbridled
primal appetites, have to offer us but a chance for we diet-
and-shape-conscious folks to live vicariously? Call it bound-
ary envy. Or rather, boundary-free envy ... Meanwhile in
58 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
the City of Fat Angels, we lounge through a slow-motion
epidemic. Mami buys another apple fritter. Papi slams his
second sugar and cream. Another young Carl supersizes and
double supersizes, the supersizes again. Waistlines surge.
Any minute now, the belt will run out of holes.
Previous work indicates that moral panics often displace
broader anxieties about changing gender roles.
hypothesis deserves further research, a recent advertisement
that ran in a major American newspaper suggests that this may
be at play in the obesity panic. This advertisement blames
‘30 years of feminist careerism’ for an epidemic of childhood
obesity and diabetes: ‘With most mothers working, too few
adults and children eat balanced, nutritious, portion-controlled
home-cooked meals. Within a generation 50% of Americans
will become diabetic, creating a medical and financial night-
mare likely to crush our healthcare system.’
epidemiological arguments about the dangers of obesity lend
credibility to such scientifically baseless claims.
Yet despite all of the moral connotations ascribed to weight
gain, we have little idea exactly why people weigh somewhat
more now than they did a generation ago. Not surprisingly, some
works suggest that increasing caloric intake and decreasing
activity levels, in some combination, are sufficient explanations
for this trend.
However, other works suggest that some
portion of the population’s weight gain can be attributed to
which runs counter to the assumption that
the country’s weight gain is evidence of both moral laxity and a
harbinger of declining overall health.
So what if the so-called ‘obesity epidemic’ is largely an illusion?
What if higher than average weight turns out to have neither
much medical nor moral significance? The answer to these
questions, all of which we believe are strongly suggested by
the epidemiological literature, go far beyond the issues of body
mass and health. The current scientific evidence should prompt
health professionals and policy makers to consider whether it
makes sense to treat body weight as a barometer of public health.
It should also make us pause to consider how propagating
the idea of an ‘obesity epidemic’ furthers the political and
economic interests of certain groups, while doing immense
damage to those whom it blames and stigmatizes.
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Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2006;35:60–67
Ó The Author 2005; all rights reserved. Advance Access publication 8 December 2005 doi:10.1093/ije/dyi255
Commentary: Understanding the
epidemiology of overweight and obesity—a
real global public health concern
and Barry M Popkin
Campos and his collaborators raise some useful and important
questions about the way to understand the impact of over-
weight and obesity on health.
Especially, bringing attention to
some of the complexities in overweight/obesity and health
relationships and covert financial interests involved in obesity
Department of Family and Community Medicine, Center on Social
Disparities in Health, University of California, San Francisco, CA, USA.
Department of Nutrition, University of North Carolina at Chapel Hill, Chapel
Hill, NC, USA.
* Corresponding author. Carolina Population Center, University of North
Carolina, 123 W. Franklin Street, Chapel Hill, NC 27516, USA.
60 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY