The Big, the Beautiful, and the Healthy?

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Tiffany Yip is teaching a graduate seminar on Multicultural Psychology and this blog was written with Vincent Corcoran, a third-year doctoral student in Fordham University's Clinical Psychology program.

Cosmopolitan UK recently announced that Tess Holliday would be gracing the cover of their October 2018 issue. This announcement was met with controversy. Why? Well, Holliday is a plus-sized model. At 5’5” and approximately 280 pounds, Holliday’s body mass index (BMI) is over 40, placing her within the “severe” obesity category. Individuals in this category are at greatest risk for obesity-related health problems as designated by the CDC. Therefore, while many have praised Cosmopolitan for battling modern beauty standards, others have questioned whether the magazine crossed a line in celebrating obesity and an unhealthy lifestyle.

This is not the first time Holliday has been on the cover of a major magazine publication, appearing on the cover of People magazine back in 2015, but this most recent appearance reignites an ongoing debate that has emerged over the last decade as obesity rates continue to rise in the US. Specifically, can someone be classified as overweight or obese and still be healthy? The majority of medical professionals would likely believe not, with a view that being overweight or obese in most, if not all, cases is detrimental to an individual’s long-term health. However, there are more and more body acceptance advocates who champion the view that individuals can be healthy at any size. So, what’s the reality? As with many polarized views, the truth may likely be found somewhere in the middle.

One critique made by the body acceptance community is that BMI as an indicator of unhealthy weight is invalid. As Tess Holliday herself once stated in a tweet, “BMI has been disproven many times.” Turns out, they're not entirely wrong. Created in the 1800’s, BMI was intended to be applied as a population statistic. However, given the simplicity of the formula, the index was eventually adopted by the medical community to be used as an indicator of unhealthy weight on an individual basis. But research has demonstrated that BMI can often mislabel individuals with a healthy amount of fat to be overweight (i.e., athletes) and fail to capture other individuals who are at-risk due to excess fat (i.e., those who carry excess fat around their abdomen). BMI fails in these instances because it is a simple function of height and weight, and does not fully account for the percentage of weight that is attributable to muscle versus fat tissue. One 2016 study, published in the International Journal of Obesity, demonstrated that using BMI alone would misclassify approximately 75 million US adults as unhealthy. However, that same study found more than three-quarters of those with a BMI over 35 were found to be unhealthy according to six other accepted health metrics. Therefore, while BMI is not a foolproof metric of health, at its more extreme values it appears to retain some utility.

Is BMI an imperfect metric? Yes. Can people with elevated BMIs still be healthy? Yes. Does carrying excess fat often increase an individual’s risk for poor health outcomes? Yes. All are true. Dr. David Katz may have said it best: “I can be okay with ‘okay at any size’ if it includes a proviso: okay at any size as long as health is not adversely affected.” Digging deeper into his sentiments, we must recognize that the obesity epidemic has not emerged from a deficiency of personal responsibility but rather a complex interaction of factors at both macro and micro levels. We should uphold the notion that weight and waist size do not equate to human worth. Urge individuals to speak up against fat-shaming and increase the presence of diverse body shapes and weights in popular media. In sum, we should avoid reducing obesity to being viewed as a moral failure, as shame has rarely ever been a strong motivator towards change. In fact, a model developed by Dr. Janet Tomiyama describes shame as a core emotional mechanism for continued weight gain when encountering weight stigma. Nonetheless, we should remain worried when models who promote living life at body extremes, like Tess Holliday, gain celebrity status. Not dissimilar to the concern that many voiced when celebrity model Kate Moss, illustrative of the harmful thin-ideal, coined the infamous tagline, “nothing tastes as good as skinny feels”.

The obesity epidemic is real and complex, with over one-third of the US population currently classified as obese. Back in 2008, annual medical costs related to obesity were estimated to be $147 billion, a figure that has undoubtedly increased. While a solution to this epidemic will not emerge overnight, requiring an amalgamation of interdisciplinary action to inform both health policy and practice, championing models of extreme body dimensions on either end of the weight spectrum may prove to be equally as damaging.