What's Wrong With Fat? (3 page)

Webster’s New World Dictionary
defines
overweight
as “above the normal, desirable, or allowed weight,” signaling a subjective aspect and an emphasis on body weight, rather than on fat composition. In 1985, the National Center for Health Statistics defined overweight as having a BMI of 27.8 or more for men and 27.3 or more for women. 22 The National Institutes of Health (NIH) lowered the cutoff to a BMI of 25 in both men and women in 1998, following reports published by the WHO in close collaboration with the International Obesity Task Force (IOTF), causing an additional 29 million Americans to become overweight overnight. 23 Some scientists contested this change, arguing that the new cutoffs were not associated with increased risk of mortality. “They have misquoted the data,” said Judy Stern, the one member of the NIH advisory committee who had voted against endorsement of the guidelines. 24 Based on current definitions, a woman of average height (5’4”) would be overweight at 146 pounds, while a man of average height (5’10”) would be overweight at 174 pounds. Based on BMI, actors George Clooney, Brad Pitt, and Matt Damon are all overweight, while Arnold Schwarzenegger is obese. 25 Oprah Winfrey is technically “obese” at her typical weight and was still technically “overweight” at her lowest weight ever of 160 pounds at 5’7” (see image 1.1 below).

Image 1.1:
Oprah Winfrey, “obese” at her highest and “overweight” at her lowest weight.

Today, sometimes U.S. researchers speak of three levels of adult obesity, including obesity 1 (BMI equal to or greater than 30 but less than 35), obesity 2 (BMI equal to or greater than 35 but less than 40), and obesity 3 (BMI equal to or greater than 40). Obesity 2 and 3 are also often referred to as “extreme” and “morbid” obesity, respectively. Based on these definitions, a woman of average height (5’4”) would be extremely obese at 204 pounds, and morbidly obese at 233 pounds, while a man of average height (5’10”) is extremely obese at 244 pounds and morbidly obese at 279 pounds.

Different measures are used for children and teenagers under 18 years old, which adjust for age. Among children, overweight and obesity is typically based, respectively, on the 85th and 95th percentiles of BMI-for-age in a specified reference population; however, the reference population varies by national context, and other methods have also been used. 26 These cutoffs were originally intended for surveillance and screening purposes only and were not meant to be indicative of a physiological state per se
.
27

Until quite recently, one did not speak of “obesity” in children at all but instead referred to those above the 95th percentile as “overweight” and those above the 85th percentile as “at risk for overweight.” The original intent of the expert committees that established these guidelines was that those with a BMI value at or above the 95th percentile of a suitable reference population would undergo an in-depth assessment to see if they were truly obese and in need of treatment. Those children with BMI values between the 85th and 95th percentile, it was thought, might also possibly be obese, although with lower probability. For them, a second-level screen was recommended, including consideration of family history, blood pressure, total cholesterol, large recent increase in BMI, and concern about weight.

The in-depth evaluation would only be recommended if any of the items in the second-level screen were positive. Over time, however, these BMI cutoffs have been interpreted as themselves establishing childhood overweight and obesity. 28 Yet, several expert committees have noted that the implications of a child’s BMI for his or her future health remain unclear. A growing prevalence of type 2 diabetes in children and adolescents is frequently cited, but this remains a very low prevalence condition among youth, occurring primarily in children with a strong family history of diabetes or who have a BMI in the 35 to 40 range or both. 29

FRAMING MATTERS

This book will show that the way fatness is framed matters. I ask: Do beliefs that fatness is a disease mean that we are less likely to blame people for their weight? Or, is obesity most often understood as a disease that people bring upon themselves? How does understanding fat as obesity affect how we feel about our bodies? How does it inform how medical professionals and the general public treat visibly fat people?

It is crucial to note that different ways of framing blame and responsibility for obesity imply different courses of action. 30 Believing that weight is under personal control may give some individuals a sense of agency and facilitate positive lifestyle changes. However, people who fail to lose weight despite their best efforts may end up feeling guilt and shame. The belief that body size is under personal control would also justify policies that make people personally accountable, by, say, charging people more for health insurance if they fall into the obese category or obligating them to buy two seats on an airplane if they are too big to fit in a single seat. In contrast, if being fat is seen as due to factors beyond personal control, one can reason that fat people deserve public accommodations, like the disabled enjoy. If being fat as a child is a serious health risk that is due to poor parenting or parental neglect, it may be seen as desirable that social services try to educate the families of fat children or, in extreme cases, even remove fat children from their parents’ custody.

If, however, one attributes high rates of obesity among the poor to food insecurity, defined as lacking the money to buy food at some point in the past 12 months, then different policy solutions are likely to be on the table. 31 For instance, one might argue that the food stamp program needs to be more generous so that people do not experience food acquisition cycles, in which food-spending peaks in the first three days after benefits are received and sharply drops at the end of the month when food stamps run out. This frame relies on research suggesting that this cycle leads to binging on high-calorie foods when the new month’s supply of food stamps arrives. 32

If blame is heaped on the food industry for encouraging unhealthy eating, this implies a need for greater regulation of this industry. If obesity, particularly among the underprivileged, is economically driven by the high cost of fruits and vegetables and the low cost of high-calorie processed foods, this would suggest a need to increase access (e.g., via subsidies) to fruits and vegetables or decrease access (e.g., via taxes) to “bad” foods and drinks. 33 If people are fat because they do not have a safe place to exercise, this may point to a need to improve neighborhood safety and provide public gymnasiums and recreational spaces. If the working poor’s weight stems from the fact that they cannot look after their health due to the pressures of working two or three minimum-wage jobs, one could argue that the minimum wage needs to be raised so that people working in these jobs have more time to eat well and exercise. Alternatively, if a penchant for cooking and eating fried food or an aesthetic preference for curvy women is to blame for higher body mass among certain ethnic groups or social classes, some sort of educational intervention may be justified. If obesity is genetically or biologically determined, it may be desirable to invest more in biological interventions. As these examples demonstrate, different ways of framing blame and responsibility imply different solutions.

While advocates for these various positions disagree about the causes of and best solutions for the “obesity epidemic,” they agree that obesity is a health crisis that urgently needs to be addressed. Indeed, the shared framing of higher body weight as obesity, that is, as medically pathological, allows a wide range of social actors to gloss over different views regarding the causes of fatness and appropriate public health responses to it. Diverse commentators may disagree about why people are getting fatter or how to stop or reverse trends in “obesity,” while concurring that higher body weights represent a pressing medical and public health problem. This is an advantage for anti-obesity advocates, as concern over a given issue is more likely to spread when there are multiple causal frames available, and when it is possible to gloss over disagreements regarding these frames
,
so long as the issue itself is generally acknowledged to be a problem. 34

The illustration below (illustration 1.1) provides a visual depiction of my argument. Here, the narrative of an obesity epidemic is imagined as an opera. From the balcony, three figures view the opera through three different opera glasses: (1) personal responsibility; (2) societal factors; and (3) biology. Each lens leads to a different interpretation of the story line. For the man with the personal responsibility opera glasses, it is a “timeless story of desire, transgression, and its inevitable consequences.” For the man with the “society” glasses, it is “a wrenching portrait of poverty and ignorance,” and the woman with the biology lenses sees “the tragic saga of a fragile soul inured in a prison of flesh.” While seeing the opera via different blame frames, all take for granted the problem frame, of obesity as public health crisis, imposed by the opera itself. Meanwhile, on the bottom left, we see an usher (a literal gatekeeper) telling a woman from a fat acceptance group, who is trying to enter the opera, to be quiet. Her perspective will not be heard this evening.

Illustration 1.1:
Different viewers see the same opera in different ways because they are looking through
different opera glasses, representing different fat frames. Illustration by Ian Patrick.

Framing fatness as a matter of health raises the stakes. No longer merely a question of appearance, fatness becomes a matter of life and death. At the same time, the reframing of fatness as a health problem, rather than, say, as a feminist issue, obscures the ways in which women are judged more harshly based on their appearance than men and are more likely to go on weight-loss diets, take weight-loss drugs, and undergo weight-loss surgery. 35

Women’s concerns about weight are as much or more about class as about health. Achieving and maintaining thinness is an important way in which the contemporary elite in rich nations, and especially elite women, signal their status. This has been well documented in France, where elite French women both are thinner and strive toward an even thinner ideal than do poorer French women, and has also been shown to be true for American elites as well. 36 The pursuit of (female) thinness is an integral part of elite and middle-class (but not working-class) habitus, or a largely unconscious, taken-for-granted, and embodied worldview. 37 The reframing of fatness as unhealthy lends medical authority to this century-old dislike for fatness among the elite and white middle classes. At the same time, it casts as irresponsible cultural preferences for heft among the working classes and, in the American context, some ethnic minorities. The idea that “obesity kills” thus can and is used as a justification for imposing elite white preferences of thinness onto working classes and people of color, in an instance of what French sociologist Pierre Bourdieu calls symbolic violence. 38
At the same time, the framing of obesity as illness brought on by bad personal choices can and is used to blame the poor, rather than poverty or inequality, for negative health outcomes.

While the United States is on the front lines, nations across the globe are fighting a world war against obesity. For instance, Japan, which has the lowest rates of obesity among the Organization for Economic Cooperation and Development (OECD) member countries at 3.2 percent, nonetheless passed a 2008 law setting a stringent maximum waistline size for anyone aged 40 and older that entailed financial penalties on companies and local governments that failed to meet specific targets. 39 France has also enlisted in the war on obesity, despite received wisdom—and supporting statistics—that French women don’t (or rarely) get fat. 40

Some researchers and journalists have disputed the public health crisis frame, arguing that the obesity issue has been blown out of proportion. For instance, a 2005
Scientific American
article entitled “Obesity, an Overblown Epidemic?” punches holes in some of the most alarmist claims about the “obesity epidemic,” including the prediction that this generation of children is likely to live shorter lives than their parents. This article quotes one of the authors of a widely cited special report that provided the original basis for this claim, explaining that the estimates were based on “back-of-the-envelope, plausible scenarios” that were “never meant [...] to be portrayed as precise.” 41 Others point out that, a more recent study suggests that the U.S. government is understating the likely rate of future
increases
in life expectancy and faces a looming financial crisis as a result. 42 Government estimates that overweight and obesity combined were associated with 400,000 excess deaths in the year 2000 were replaced with news estimates of less than 30,000 the following year. 43 And a growing body of literature on the “obesity paradox” documents health advantages to having a BMI greater than 30. 44