Thursday, April 7, 2011

Fat phobia, the "obesity epidemic" and the medicalization of inequality

     Recently Toronto's progressive weekly newspaper, NOW, had a photoshopped front cover and feature pages showing rightwing mayor Rob Ford posing naked. This was clearly aimed at making fun of his weight, a recurring theme. When he announced he was running, NOW wrote about it in an article titled "fat chance", and during the election campaign right-wing rival George Smitherman suggested he "doesn't have the fitness for the rigour pace" (comments reinforced by media photos of his abdomen).  Last week while I was leafleting for the April 9 rally to protest Rob Ford's policies, one passerby grabbed a leaflet and called Ford a "fat fuck", a term reproduced on youtube clips and internet sites.
     There's plenty of reasons to criticize Rob Ford--from his racism and homophobia to his attacks on transit workers and public services--but his weight is not one of them. NOW defended itself on freedom of speech grounds, but that's besides the point. Free speech shouldn't pander to fat phobia or any other form of oppression. As one blogger noted,
"Ask yourself if NOW would ever do a Photoshopped cover of a female mayor in her underwear? The naked truth is that NOW would never have dared such a cover with Barbara Hall as mayor...Or if George Smitherman was the new mayor, can you imagine a cover with his worship wearing nothing but chaps and making fun of his sexual orientation?"
     One of the reasons fat phobia is so accepted is because it's become medicalized, giving it a veneer of legitimacy.  We're told that we live that we're gripped by an "obesity epidemic", which kills 300,000 Americans a year, a "threatening storm" that an article in the New England Journal of Medicine blames for a future decline in life expectancy. The policing of body size has entered daily medical practice with the "metabolic syndrome", a concept aimed at describing the inter-dependence of diabetes, high cholesterol and high blood pressure; to assess for this every family doctor is trained to measure their patient's blood pressure and lab weight circumference. We're then supposed to council patients to "chose a healthy lifestyle" based on low-fat foods, on the notion that this will reduce obesity and its associated health problems. But this picture doesn't fit reality.
     Despite the focus on evidence-based medicine, much of the "obesity science" is arbitrary. Gerald Reaven, a leading scientist on insulin resistance, exposed the pseudoscience behind the metabolic syndrome, especially its inclusion of waist circumference:
"Not only are the cut points for the five chosen criteria arbitrary, there is no reason to believe that the individual elements of the metabolic syndrome are equally reflective of either the presumed basic defect or the risk of cardiovascular disease...although being overweight/obese increases the chances of an individual being significantly insulin resistant, by no means are all overweight/obese individuals insulin resistant, and, of greater clinical relevance, weight loss in overweight/obese individuals who are not insulin resistant does not lead to substantial clinical benefit."
 The site has also busted the "300,000 deaths a year" myth, noting that the authors of the quoted study objected to the misrepresentation of their findings, and that furthermore: 
"[the study] may have actually built upon the results of the 20 year long Cooper Institute Studies of 20,000 men which showed that fitness level and amount of exercise determined the morbidity risk rate regardless of what people weighed i.e. fat couch potatos and thin couch potatoes seemed at equal risk whereas fat exercisers seemed at no more risk than thin exercisers and at much less risk than thin couch potatoes."
     Not only does the supposed problem "fat = unhealthy" not stand up to scrutiny, but the supposed solution of lecturing people to "stop eating fat" doesn't reduce weight or the supposed obesity-related illnesses. The Women's Health Initiative followed 50,000 women for years, telling one group to eat a low-fat diet while the control group followed their usual diet. The results:  "Women assigned to this eating strategy did not appear to gain protection against breast cancer, colorectal cancer, or cardiovascular disease. And after eight years, their weights were generally the same as those of women following their usual diets." Despite the simplistic call for "good lifestyle choices", people can choose health in the same way that they can choose housing, income, working conditions, the food they eat, the air they breathe. In the market, people's ability to make choices depends on their socioeconomic condition.
     Last month, Scientific American published a study on the "diabetes belt" through the US:
the diabetes belt
"Going past national statistics, a new map shows more than 640 counties in mostly southern states had higher-than-average rates of diabetes, suggesting the need for more targeted prevention...the 644 counties in the diabetes belt match up to known risk factors for the disease, including: a high obesity rate, sedentary lifestyles, lower education levels, and more non-Hispanic blacks...The 15 states that have counties in the diabetes belt are Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and West Virginia." 
the poverty belt
But there is a clear marker, almost universally ignored, that matches both diabetes and those "risk factors": poverty. These 15 states include 11 states with the highest poverty rates: Alabama, Arkansas, Georgia, Kentucky, Lousinana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and West Virginia. Fortunately not all the medical literature ignores poverty and income inequality. In another article in the New England Journal of Medicine--"Class, the ignored determinant of the nation's health", the authors reveal that:
"On the whole, people in lower classes die earlier than do people at higher socioeconomic levels, a pattern that holds true in a progressive fashion from the poorest to the richest... Unhealthy behavior and lifestyles alone do not explain the poor health of those in lower classes. Even when behavior is held as constant as possible, people of lower socioeconomic status are more likely to die prematurely."
     This is not to say that personal agency is not important. On the contrary: challenging the social and economic conditions that constrain choice is the best way to promote personal agency. Instead, many studies on obesity take these conditions for granted, controlling for differences in race and occupation—either explicitly, or implicitly by enrolling white middle-class people. This means filtering out the health impacts of racism and class, two of the most potent determinants of health. The premise is that these are natural and unchangeable, and should be eliminated from analysis, and that instead we should blame the difference in weight amongst ourselves. (For other good blogs on the obesity-shaming epidemic go visit here and here.) While this perspective is not medically useful, it serves economic and ideological purposes. 

     The fear mongering about obesity can't be separated from the market that profits from it--from the multibillion dollar diet industry, to commercialization in general that thrives on reducing people's self-esteem so it can sell them a product. Meanwhile, the Canadian guidelines for the treatment of obesity were written by the president of Obesity Canada (an organization sponsored by food and drug companies) who owns stocks in Glaxo-Smith Klein and Eli Lilly, two pharmaceutical giants who happen to sell anti-obesity drugs. Like all free market industries, the pharmaceutical industry is made up of rival firms competing for market share. In the field of health this produces a pressure to pathologize (especially women). Obesity was turned into a "risk factor", and now its own disease, making fat phobia a very modern phenomenon.

     But medicalized discrimination is far older. Far from being objective and neutral, medical ideology plays an important role in policing society, by pathologizing those who don't conform to narrowly-defined norms. Instead of focusing on economic conditions that collectively put us at risk of diabetes and heart disease, the obsession with obesity personifies these diseases, presenting them as the result of individual, lazy, and reckless behavior. The obsession with obesity recalls other instances in which groups of people have been labeled as “abnormal” or “at risk” because of their shape, origin, sexual orientation, gender identity, ability, and religion.
     The obsession with measuring people's waists in order pass to judgment on them is reminiscent of the early pseudoscience of phrenology, which measured people's heads as a basis of justifying social inequalities. Almost every oppressed group has at one time in history been blamed for an infection disease: First Nations blamed for TB, European Jews blamed for chlamydia, Mexican-Americans blamed for typhus, African-Americans and sex-trade workers blamed for syphilis, Haitians and gay men blamed for AIDS. Homosexuality was considered a psychiatric disease until the Gay Liberation Movement. Transgender people continue to fight against being pathologized. People with disabilities call for a broader definition of health instead of mainstream medicine's desire to “fix” them. Muslims are resisting attacks on civil liberties that use the language of “public safety” in order to restrict their rights to movement, attire, athletic competition, occupation, and voting.
"social hygiene" warning
     In all these situations the “target of intervention” has been the supposedly monolithic and deviant behaviours of oppressed groups rather than the social and economic conditions that place them, and others, at risk. The results have been social stigma or repressive laws, rather than accessible health care, better housing, and higher wages. In the 19th and 20th century when infectious disease dominated there was a "social hygiene movement" that provided medical justification for a moral crusade against deviant sexuality (everything from dancing to prostitution, along with homosexuality and inter-racial partnerships) but as the major medical problems for industrialized countries have shifted to diabetes, heart disease and cancer, the source of the blame has shifted from people's hygiene to their size. This ignores the real problems that threaten to undermine life expectancy: income inequality, lack of health care, unhealthy food driven by competition in the food industry to make things as cheaply as possible, and cuts to social services that deprive schools or community centres of fitness opportunities. (For a discussion of how biomedical reductionism affects our understanding of cancer, see my other posts here and here).

     The most important determinants of health are: 
1. Income and Income Distribution 2. Education 3. Unemployment and Job Security 4. Employment and Working Conditions 5. Early Childhood Development 6. Food Insecurity 7. Housing 8. Social Exclusion 9. Social Safety Network 10. Health Services 11. Aboriginal Status 12. Gender 13. Race 14. Disability
These are the issues on which to challenge Rob Ford; not his body but his policies that undermine the key social determinants of health. That's why thousands of people--representing a healthy diversity of bodies united in the demand for a better and healthier world for all--will be protesting this saturday. Fat phobia not welcome. 


  1. Dr J, thank you SO much for this post (which I will read in more detail over the weekend).

    I've written professionally about eating disorders, and from there became really interested in the pseudoscience behind fat-phobia, and how it's inextricably bound up with the cosmetic/fashion/celebrity/surgery/diet-industry consumption machine. And how sexist - and unhealthy - and unequal it is. So I'm really interested in your perspective on this.

  2. Thank you for your post! I've provided the link in the penultimate paragraph.

  3. An excellent post, as always, and some good stuff on how obesity is used as a form of moral panic that, like others, serves to discipline and humiliate working people.
    However, I think that you are overstating your case and risk losing other political, historical and health points in the process.
    First, it is simply not true that it doesn't matter whether we are obese or not. It's not true that obesity and slimness are irrelevant categories and I think that you're cherry-picking your data here. Obesity is not a normal physical state and has to be understood as a sign of pathology and a risk factor for other diseases. It is not a coincidence that rates of diabetes have risen along with rates of obesity since the 1970s, for instance.
    Along those lines, it's also a mistake to dismiss metabolic syndrome as a made up disease designed to fill the coffers of pharmaceutical companies. There are a couple reasons why this is dangerous. The first is that it puts progressives in the rather awkward position of saying that nothing is wrong. There is something wrong with the fact that 70% of US adults are overweight or obese and that 65% of Cdn males are also - even if we accept that the category of obese/overweight is a loaded one. This is a sign of unhealthy diets. Humans in their natural state are not obese - just like other primates.
    To claim that there is no problem with being obese and that it is a made up problem makes us look like conspiracy theorists. Pharmaceutical corporations definitely try to "big up" and medicalize states of health in order to sell drugs - the present mad dash to produce "diabesity" and obesity medications, implants and surgical procedures to regulate hunger, etc is proof of that. So is the massive boom in drugs for children with ADHD. Does that mean that children acting out is a myth generated by the pharmaceutical companies? Or does it mean they've taken the real-life experience of parents and made it into a medical condition to be fixed with drugs? I think that it is the latter. Why are children acting out more than in the past? Perhaps its the change in diet to include more sugar or the fact that parents are working more to make ends meet and not able to pay attention to their kids. Perhaps it's the cuts to community sports programs, etc. (probably all of the above, frankly) But if you tell people that they're experience is invalid, you'll convince no one.
    Secondly, something HAS changed since the 1970s. People are heavier - by close on 15% in the USA (unless you can show that the criteria has changed). I would argue that the rise in obesity and overweight is a product of the austerity that accompanied the end of the post-war boom and the assault on living standards and unions. To give one example, the McGovern Commission - a Senate standing committee that began in the early 1970s - started with the mandate of looking at hunger in America. It was a Keynesian committee in its intention. But by the end of the committee and the publishing of its recommendations in the late 1970s, it had expanded its mandate to look at "overeating". It's publication of the now-ubiquitous food pyramid, with its heavy emphasis on "low fat" and high carbohydrate, grain dominated diets played an important role in shifting the North American diet. This wasn't a conspiracy to make people obese but it was an expression of a growing sense amongst the elite that workers and trade unionists were too greedy. They were over-eating and this needed to be reined in. Expectations needed to be lowered. It was the nutritional arm of the overall offensive that is neo-liberalism.
    So, I don't think that we need to either accept that being obese/overweight is healthy or believe that it is a sign of moral depravity, personal weakness or even to reduce all illness to it. We don't need to be juvenile and idiotic like NOW Magazine (who, frankly, demonstrate nothing so much as their own snobbish elitism and provide Ford with populist ammo).

  4. A few thoughts:
    Dr. J - I should develop the habit of reading your blog, as I learn something every time :)
    Obesity is a real social phenomena, all over the industrial world. Counter-intuitively, industrial nations share or even lead many problematic health indicators that derive from diet - heart disease, cancer, diabetes, etc. It isn't strictly a creation of the pharma industry. If anything, it's a creation of the industrial nature of our food supply. North Americans, it is said, are carrying around the national grain surplus on our belt lines. A regular diet of high-carb, non-diverse corn-derivative diets has produced the 'epidemic of obesity'. It's not a creation of drug companies.
    What IS the case is that the drug companies are happy and willing to pathologize it and package a 'cure' that can then be sold back to the consumers who have been killing themselves slowly on a regular diet of corn and it's derivatives (grain-fed meat, sodas, pretty much ALL processed food has a corn derivative in it, many times as the main ingredient).
    So Dr. J, I agree that we should be focusing on Ford's reprehensible politics and not his waistline. I don't think we need to stick-bend though, away from obesity as a geniune phenemona.
    Redbed - I suspect our bodies are as much a product of our society as everything else is, so using terms like 'natural' puts the argument on dangerous ground. In some ways (and the chinese are now proving this), for a person living where the industrial food supply is the easy or only option, the 'natural' state may very well be obesity! Chinese eaters are now gaining unhealthy weight in unprecedented numbers. Same thing with 'normal physical state' - what's 'normal'? Is normal the average, in which case normal means 'carrying 10 - 30lbs of unnecessary (for sustainable life functions) fat around, as so many westerners do? Or is normal something like 'when we think of a healthy person, what we think of is 'normal physical state'? By that convention, many athletes (who, for example, have wacky BMI scores because of so much muscle mass) wouldn't be considered unhealthy - which may of course be true! OK, bad example...
    I think that: the cause of individual obesity is social and thus the solution must be social (It would be more effective combating unhealthy weight by banning Mcdonald's, KFC, and soda pop, than be creating a pill that would glom onto fat or sugar molecules and stop them being absorbed, for example). But at the same time, it's true that eating is an individual action and individuals should be in a position to make better choices about their diet. That means fighting for a diverse, organic food supply and it means fighting individually those poor diet choices.
    Lastly, let's stop pretending NOW magazine is 'progressive'; they are mostly smug urban hip, and sometimes that means progressive and sometimes it means totally missing the real problem of Rob Ford, and focusing instead on a cheap (and tasteless) joke.

    My two cents

  5. Thanks for the comments Redbedhead and Jonathan (and thanks to your blog Redbedhead for encouraging me to start one).
    I don't think obesity is a fabrication of Bigpharma (and only devoted the smallest paragraph to pointing out the economic aspects) and don't deny there's a health crisis. What I question is the ideology of reducing the latter to the former, blaming body size rather than the socioeconomic factors you outlined.
    As Michael Pollan has described, there's been “a radical and abrupt set of changes over the course of the last 150 years, not just to our foodstuffs but also to our food relationships, all the way from the soil to the meal”. This is connected to broader changes in society, from a longterm concentration and centralization of capital--leading corporations to produce low nutrition high calorie food laced with pesticides and preservatives and stored in BPA-filled containers--to the more recent attack on living standards from the neoliberal offensive. As you've both outlined, this has imposed a very real experience on the majority of people who are forced to eat unhealthy food while immersed in toxins in the environment/food/workplace. As a result there's an epidemic of diabetes, as well as cancer. (Americans are also an inch taller than they were a generation ago, but this deviation from "normal" is praised because it conforms to the current standards of beauty).
    While the cancer epidemic is being ignored, the diabetes epidemic has been personified as the "obesity epidemic". This depoliticizes, fragments, and individualizes the causes of the health crisis, leading people to blame certain people's bodies instead of the collective conditions we need to change so we can all live healthier lives.

  6. Dr. J - Yeah, I think that we're mostly in agreement and I don't think that the present health crisis is reducible to obesity. The majority of the "health crisis" is in fact the lack of accessible healthcare. In the USA it is obvious but the de-listing of services here has also made a lot of medical care inaccessible (and having just paid over $2000 to deal with the fall-out of a herniated disc, I know this well).
    Ironically, the present moral panic about obesity is a continuation of the "greedy worker" meme from the 1970s that contributed to ratcheting up obesity in a big way with all the obsession with low fat and relatively high carb diets. It's doubly ironic that the worse our food gets the fatter we get as a society and thus the more we are admonished to lose weight.
    Nonetheless, while I think that environmental toxins, like pesticides and PBA, contribute to some of the cancer numbers, diet and "lifestyle" plays a much bigger role. I don't have the quote in front of me but Gary Taubes in his book, Good Calories, Bad Calories, reckons diet and lifestyle related cancer causes as being about 90% of the total. And obesity, like diabetes and colon cancer (and even Alzheimer's), etc are all inter-related very tightly with the dietary changes of recent times - accelerating rapidly post-WW2 and then even further since the 1970s. The obvious solution to these problems is to ban shitty, unhealthy food as the poison that it is and to direct the, literally, hundreds of billions of dollars in research into "drug targets" for all of the diet related diseases into food programs, urban agriculture, organic agriculture, etc. That would kill a lot of birds with one stone. Hell, if we redirected the $1 trillion or so that goes on various aspects of the US defense industry, we could send everyone a grass fed cow free of charge and give the whole damn continent a raise.

  7. On the other hand, Samuel Epstein argues that most cancers are environmental, while Stephen Bezruchka makes the point that the health of societies is less related to their healthcare system (though he takes this argument to the extreme) and more about the inequality of society--which has nothing to do with the size of its people.

    But I do like your plan of diverting $1 trillion military spending into organic cows. Cows not bombs!

  8. This is a good read.
    Typo, 3 paragraphs from the bottom, "Transgered people continue to fight against being pathologized" should read "Transgender people...". Note it's not "transgenderED".

  9. This post is killer. Thank you!

  10. Hi Dr. J,

    I'm sorry but I can't seem to find a 'contact' button on your blog so this comment on this very old post is the only obvious way to contact you. I am interested in holding a workshop on Fatphobia in schools at my university (U of T, initial education), and your opinion as a physician would be very valuable. Can you email me at tanya [dot] herbert [at] gmail [dot] com if you are interested in giving a brief talk to future teachers? Thanks!