Why “Morbid Obesity” Still Hurts — and Why the Language Matters

[TheBigBlue]

There's solid research showing a strong association between childhood trauma and adult obesity. Trauma affects the stress-response system, emotional regulation, and health behaviors across the lifespan. So for many of us with CPTSD, weight is not a simple "willpower issue" but a long-term biopsychosocial consequence of early adversity.

And then there is the term "morbid obesity."

"Morbid" literally means deadly. It's still used by many clinicians for the most severe form of obesity (BMI ≥ 40), even though the WHO's ICD-11 now uses the more neutral Obesity Class III. The CDC also explicitly advises health professionals: "By using clinically accurate terms such as 'Class 3 Obesity' instead of 'morbid obesity due to excess calories,' providers can create a more supportive environment for patients with obesity" and "... can help reduce weight bias and stigma ..." (https://www.cdc.gov/obesity/media/pdfs/2024/12/adult-partner-promotion-materials-icd-10-codes-508.pdf).

But in practice, this hasn't filtered into everyday care. Many of us still read on their charts or walk into appointments and hear:
"You are morbidly obese."
"Morbid obesity is your main problem."

Calling someone "morbidly obese" is like diagnosing a patient with "deadly cancer" instead of "stage 4 cancer". Morbid is not a neutral descriptor - it hits with the full weight of stigma.

For trauma survivors, the impact is amplified:
- CPTSD already comes with shame, body distrust, and a long history of being blamed or judged.
- Early relational trauma and neglect shape the nervous system and often the body.
- Then the medical system mirrors the childhood message: You are the problem.

"Obesity Class III" still communicates medical risk. But it just doesn't define the person as morbid.

Language won't fix trauma, but it can stop adding new wounds.
The coding system has already changed. The science has already moved.
It's time for clinical language to follow.

[sanmagic7]

it is, indeed!

[Kizzie]

Spot on TheBigBlue!   

When my son was in medical school (just graduated in May), he had a class where the doctor speaking was using some derogatory/flippant language about patients who are obese such as "a heart attack waiting to happen" and so on. I'm delighted to say that he and his fellow students texted each other about how this kind of "fat-shaming" was simply not on in a course. They then went to their Dean to complain and happily they were well received and action was taken to remind faculty that this kind of shaming language was not permitted. So, progress is on the horizon!

I personally would like to see complex relational trauma survivors referred to not as disordered, but as injured. This puts the onus, not on us but on our perpetrators and normalizes our symptoms as responses to abuse/neglect rather than some kind of character defect.

[TheBigBlue]

Thank you, Kizzie, your comment really meant a lot. It's encouraging to hear about your son and his classmates pushing back against that kind of shaming in medical training. That's exactly the shift we need. 
And I fully agree with calling us injured rather than disordered - it captures the reality so much more truthfully. Appreciate your perspective.

[Kizzie]

 

[Blueberry]

Thank you for bringing this up, TheBigBlue. Language does matter! Shaming us doesn't help, except to maybe help those who shame us. They can feel all healthy, and smug.

Kizzie, I appreciate the response of your son and his fellow students!

[TheBigBlue]

 

[Dalloway]

your post TheBigBlue

[alliematt]

I know the feeling. I have that label and it feels so personal.

[Kizzie]

I asked AI to search "obesity and Complex PTSD" and here's what it came up with:

Complex PTSD and obesity are linked through shared physiological and psychological pathways, such as chronic stress, inflammation, and hormonal dysregulation, which can lead to weight gain, metabolic dysfunction, and increased cravings for high-calorie foods. The trauma response can alter appetite-regulating hormones like cortisol, leptin, and ghrelin, while also leading to coping mechanisms like "food addiction" or binge-eating to manage emotional distress. Addressing both psychological and physical health is crucial for treating these interconnected issues.

What is interesting is that when I went to Google Scholar, lots of research about PTSD and obesity - very little about Complex PTSD that I saw after doing a quick search. A lot of what the PTSD articles talk about is food addiction as a way of self-soothing which in our case leaves out the bodily responses we have due to protracted exposure to traumatic stress. The good thing about searching with AI on is that it looks at a vast amount of research data so it is there, but it's not as easily found. 

I'm going to dig a bit more because it's something that those of us dealing with obesity need healthcare providers to understand.  That is, it's an issue with both medical and mental health components, which to my mind makes dealing with it just that much more difficult.

[TheBigBlue]

Thanks, Kizzie! I was also doing some more digging - here is my summary (sorry it got kinda long):

Multiple independent meta-analyses (i.e., studies that pool data from many original studies) report that Adverse Childhood Experience (ACE) exposure is associated with higher odds of obesity. Across these analyses, exposure to any ACE is typically associated with about a 1.3–1.5-fold increase in odds of obesity, and higher ACE counts (≥4 ACEs) are associated with approximately 1.5–2.0 times the odds of obesity compared with no ACEs. These studies consistently demonstrate a graded increase in the odds of adult obesity with increasing ACE counts and discuss plausible mechanisms including chronic stress and HPA-axis dysregulation, health behaviors, and social and environmental factors.
Especially treatment-resistant obesity is strongly associated with developmental trauma in the clinical literature.
------------------

Why an average of 1.5–2× is far more dramatic than it sounds

1) Obesity is a multi-determined endpoint, so odd ratios in this range are considered as large.

Obesity is not driven by a single pathway. It involves: genetic factors, metabolic and endocrine regulation, socioeconomic background, medications, sleep disruption, chronic stress and trauma, food environment, physical limitation and chronic illness.

When an outcome has dozens of independent determinants, most individual predictors contribute only very small effects. In epidemiology, odds ratios above 1.2–1.3 are already considered meaningful for such complex endpoints.

Thus, ACE-associated odds ratios of 1.6–2.0 are substantial, comparable to the effect sizes of other major public-health exposures such as:
- low socioeconomic status on cardiovascular events
- early smoking-related increases in cancer risk

These are not small effects; they are clinically and public-health-level significant.

2) The "1.5–2×" figure is an average across highly heterogeneous trauma, and therefore an underestimate for people with CPTSD.

Meta-analyses combine mild neglect, moderate adversity, and severe, chronic abuse into the same categories. This dilutes the effect size. CPTSD, by contrast, is the endpoint of severe, repeated, and developmental trauma, which clusters in the highest-risk ACE categories.

Large-scale data from the ACE Study show: ACE ≥6 → 2.5–3× increase in severe obesity (Felitti et al., 1998).

Therefore, the commonly cited "1.5–2×" figure understates the risk for individuals who experienced multi-layered, chronic developmental trauma, precisely the population in which CPTSD develops.

3) CPTSD involves specific trauma-related biological mechanisms that strongly predispose to weight dysregulation. CPTSD is not just a psychological condition, its neurobiological footprint directly affects systems involved in appetite, metabolism, and weight, such as:

3A. HPA-axis dysregulation (chronic cortisol elevation):
- Chronic childhood trauma → long-term cortisol disruption →
- increased visceral adiposity
- insulin resistance
- increased appetite for high-fat/high-sugar foods
- reduced satiety signaling

3B. Altered reward processing and emotional regulation:
- Developmental trauma changes dopaminergic reward pathways, producing:
- emotional eating as a distress-regulation strategy
- increased susceptibility to binge-type coping
- reduced interoceptive awareness (hunger/fullness cues)

3C. Sleep disruption, hypervigilance, and autonomic imbalance:
- CPTSD involves chronic autonomic dysregulation:
- hyperarousal and sleep fragmentation
- elevated sympathetic tone
- reduced vagal tone
- impaired glucose metabolism

These are well-established mediators of metabolic dysfunction.

3D. Early developmental programming; Childhood trauma affects:
- early establishment of eating patterns
- neurodevelopment during sensitive periods
- long-term epigenetic regulation of stress and metabolism

This means that CPTSD is not "adult stress", it represents a childhood-built stress system that confers lifelong vulnerability to weight dysregulation.

4) Medical impairment and trauma magnify each other. The meta-analyses do not adjust for real-world amplifiers such as:
- chronic pain
- mobility impairment and disability-related barriers to movement
- medication side effects
- socioeconomic consequences of trauma
- repeated retraumatization in adulthood

In individuals with CPTSD plus medical disabilities, the combined effect is multiplicative, not additive.


Key sources include:
1. Amiri et al., 2024 – "Adverse Childhood Experiences and Risk of Abnormal Body Mass Index: A Global Systematic Review and Meta-Analysis"

2. Wiss & Brewerton, 2020 – "Adverse Childhood Experiences and Adult Obesity: A Systematic Review of Plausible Mechanisms and Meta-Analysis of Cross-Sectional Studies"

3. Danese & Tan, 2014 – "Childhood maltreatment and obesity: systematic review and meta-analysis"

4. Moriya et al., 2024 – "Association of adverse childhood experiences and overweight or obesity in adolescents: A systematic review and network analysis"

5. Felitti et al., 1998 – "Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study"

[Kizzie]

Awesome BB, thanks for digging up and summarizing all this info. It is such a relief to see that the data confirms what I intuitively knew must be the case. I quit smoking in the days before Nicorette (which has been likened to quitting heroin), with far less hardship than I've had dealing with eating issues.

We all have to eat whereas we don't have to smoke/take drugs/gamble, etc., so the constant exposure to food is something we must contend with. Still, that doesn't entirely explain the differences between survivors and non-survivors as the research indicates. There really are differences relating to trauma, psychological yes but also physiological.

This is really important info for medical/mental professionals, nutritionists/dieticians, etc., to know in order to develop more robust/effective treatments than basically "Just eat less and exercise more." That just doesn't address the struggle many of us have with food and makes us feel like failures.

I would love to talk with a professional who gets that I am different and is open to helping in a way I can relate to, that takes into account my trauma. I have seen my fair share of dieticians over the years and not once did I feel comfortable revealing my background. Sure I've had the 'emotional' eating chats many times, but I imagine if I told those I saw just how 'emotional' and stressful and chaotic life was for me they would not have known what to say. 

Time for change!