In the 2011 documentary Fed Up pediatric endocrinologist Dr. Robert Lustig, discussing the use of medical imaging to investigate body composition, states that “when you slide somebody [who is thin] into an MRI and you actually visualize the fat, they might as well be obese” (Soechtig 1:12:59-1:13:14, emphasis mine). The statement accompanies footage of fat teen interviewee Brady Kluge and his thin(ner) brothers undergoing x-ray scans that reveal to viewers that Kluge’s brothers are secretly, as Dr. Mark Hyman states, “skinny-fat kids” (1:14:14-1:14:21).

            The term skinny-fat is introduced in the documentary in virtually the same breath as TOFI, or thin-outside-fat-inside, a term coined by Dr. Jimmy Bell and collaborators at Imperial College London to “identify and fully characterize a novel subphenotype at increased risk of insulin resistance, despite their normal BMI.”  While skinny-fat most often is used to refer to people with “normal” BMI but lower muscle mass, TOFI focuses on higher levels of visceral and liver fat. The choice to use these phrases may appear to subvert normative assumptions about the relationship between health and weight, showing that thinness does not automatically equal wellness. Skinny-fat and TOFI, however, are merely reiterations of the same anti-fat ideology that governs much of our modern world, a world that Mark Graham has described as “lipoliterate” due to our propensity to read fat bodies to discern the character of the individual. When all bodies harbor the potential for being “obese,” even without outwardly appearing so, the fight against “globesity” takes on a new dimension.

            Kenneth Burke’s concept of terministic screens highlights the significance of the terms we use to describe our reality and reminds us that, “[e]ven if any given terminology is a reflection of reality, by its very nature as a terminology it must be a selection of reality; and to this extent it must function also as a deflection of reality” (45). Any number of labels could be chosen to describe the health risks associated with higher visceral fat or proportionally lower muscle mass. The choice to define health risks experienced by thin or “normal weight” individuals directly in relation to fat bodies trades on the existing power of anti-fatness, generating political and economic benefits for various industries invested in the production of an “obesity epidemic.” As Alice Julier argues, “When fatness is conflated with irresponsible behavior, those who are not fat—who ‘treat’ and construct a public agenda based on controlling the obese—gain status” (548). Extending conceptions of fatness expands the status available to the few who can claim true “wellness” or can market their knowledge around weight loss, relegating countless others to the endless pursuit of a near-unattainable standard of both inner and outer thinness (understood to mean health).

To label someone as TOFI generates suspicion around the venerated health status of the thin body, reversing the common weight-loss trope of the thin person hidden inside the fat body, desperate to be freed. It does not, however, challenge stigma against fat bodies in the process. Le’a Kent describes the insidious logic underpinning the before-and-after trope, writing that “the self, the person, is presumptively thin, and cruelly jailed in a fat body. The self is never fat… situating [the fat body] as that which must be cast aside for the self to truly come into being” (135). The idea of a thin-outside-fat-inside person introduces a new source of fear in the moral panic around weight, suggesting that “obesity” can be a mental as well as physical affliction. While the term may literally describe the less visible fat around the organs, both TOFI and skinny-fat imply something much deeper and more substantive at issue: an abject fat self that must be cast aside to re-establish a harmony between the outer body and the inner self.

Thinness under such logic thus becomes a veneer of well-being that could obscure an apparently dangerous reality, allowing a “metabolically obese” person to masquerade as one of the well (understood as someone with “normal” BMI). The thin outside is mere camouflage, an obfuscating factor. What is at stake in these terms is not just the literal visceral fat or the lack of muscle, but the sense that the person is at odds with themselves, that they might as well be “obese.” Given the heavily moralized nature of “obesity” and “overweight,” asserting that someone should be “obese” naturally carries a judgment about that person. Skinny-fat and TOFI people appear to be victims of an inner deficiency, despite passing as “normal.”

            TOFI and skinny-fat have another important function: revealing the constructed and insufficient nature of “overweight” and “obesity” as medicalized (and moralized) categories. If it is not simply someone’s size or BMI at issue, but rather a multitude of other factors including musculature, diet, fitness, and visceral fat distribution, then treating “excess” body size as a discrete medical (and pathological) category seems epistemically unjustified. This is particularly true when fatness is treated as both an external and an internal affliction, something that both thin and fat people can experience in different ways. Despite the pretense of science and objectivity with which medicine cloaks itself, the language we choose to discuss and debate health and wellness is not neutral and can often constrain if not predetermine conclusions.

 Cover Image: Rrawer, Ganzkörper DEXA Scan, 2007. (

Works Cited

Burke, Kenneth. Language as Symbolic Action. University of California Press, 1966.

Graham, Mark. “Chaos.” Fat: The Anthropology of an Obsession. Eds. Don Kulick and Anne Meneley. New York: Penguin, 2005, pp. 169-184.

Julier, Alice. “The Political Economy of Obesity: The Fat Pay All.” Food and Culture: A Reader, Eds. Carole Counihan and Penny Van Esterik, Taylor & Francis, 1997.

Kent, Le’a. “Fighting Abjection: Representing Fat Women.” Bodies Out of Bounds: Fatness and Transgression. Eds. Jana Evans Braziel and Kathleen LeBesco. University of California Press, 2001, pp. 130-150.

Soechtig, Stephanie, director. Fed Up. RADiUS-TWC, 2014.

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